3rd Annual Apothecary Dash 5K & 10K


VA Medical Center campus at ETSU, Johnson City, TN

3/1/2014


Registration will start at 9:00 AM
Both races begin at 10:00 AM
ALL proceeds are donated to Relay For Life & the American Cancer Society
All pre-registered runners will be guaranteed a t-shirt at the event.
You may also register as a group of 10 or more to receive 50% off the registration fee.
Water and a variety of snacks will be provided before and after the race. Water will also be available during the race.

Pre-registration:
(ends 2/1/2014)
$20 pre-registration fee for either the 5K or 10K race. | Regular
| Registration:
Regular registration begins February 2nd 2014, and will continue until the day of the race. You can still register the day of the event. The cost for regular registration will be $25.
Make checks payable to: Kappa Psi
Mail this form to: Kappa Psi
P.O Box 106
Mountain Home, TN 37684
All pre-registered runners will be guaranteed a t-shirt at the event.
You may also register as a group of 10 or more to receive 50% off the registration fee.
Water and a variety of snacks will be provided before and after the race.
Headphones are permitted on the course | Strollers are permitted on the course
For more info contact
For more information, please contact one of the following:
Nick Kirkpatrick: kirkpatrickn@goldmail.etsu.edu or,
Whitney Varney: varneyw@goldmail.etsu.edu
704-465-7048
3rd Annual Apothecary Dash 5K
Male & Female Awards:

Top Overall
Top Masters
Top GrandMasters

Age Groups (top 3)
...19, 20-39, 40-59, 60...
3rd Annual Apothecary Dash 10 K
Male & Female Awards:

Top Overall
Top Masters
Top GrandMasters

Age Groups (top 3)
...19, 20-39, 40-59, 60...

3rd Annual Apothecary Dash 5K & 10K

LAST NAME__________________________________ FIRST NAME_________________________ M.I._______

SEX____ DATE OF BIRTH____/____/____ AGE ON RACEDAY_____ E-MAIL____________________________

ADDRESS___________________________________________________________________________

CITY________________________ STATE_________ ZIP___________ PHONE (_______)_______-___________

RACE DAY EMERGENCY CONTACT (NAME AND PHONE)_________________________________________

TEAM NAME____________________________

*** CIRCLE EVENT: 3rd Annual Apothecary Dash 5K | 3rd Annual Apothecary Dash 10 K

*** CIRCLE SHIRT SIZE: YM, YL, SM, MD, LG, XL,

IN CONSIDERATION FOR ACCEPTING MY ENTRY IN THIS RACE, I FOR MYSELF, MY HEIRS, EXECUTORS AND ADMINISTRATORS, WAIVE AND RELEASE FOREVER ANY AND ALL RIGHTS AND CLAIMS FOR DAMAGES I MAY HAVE AGAINST THE ORGANIZERS AND SPONSORS OF THIS EVENT. I ALSO RELEASE THE ABOVE NAMED FOR ALL CLAIMS OF DAMAGE DEMANDS, AND ACTIONS IN ANY MANNER DUE TO ANY PERSONAL INJURIES, PROPERTY DAMAGE, OR DEATH SUSTAINED AS A RESULT OF MY TRAVELING TO AND FROM AND MY PARTICIPATION IN SAID RACE. I ATTEST AND VERIFY THAT I AM PHYSICALLY FIT AND HAVE SUFFICIENTLY TRAINED FOR THE COMPETITION OF THIS EVENT. IN FILLING OUT THIS FORM, I ACKNOWLEDGE I HAVE READ AND FULLY UNDERSTAND MY OWN LIABILITY AND ABILITY.

SIGNATURE_____________________________ DATE_____/_____/_____ (Parent signature if under the age of 18)


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