3rd Annual BREAK AWAY 5K Race to End Domestic Violence


Municipal Parking Lot - Water Street, Gate City, VA

9/13/2014


8am - 5K Run

This is the 3rd Annual Break Away 5K Race Against Domestic Violence. All proceeds go to support Hope House of Scott County, Inc. T-Shirts guaranteed for those who register on or before Sept.6th. Those who register on or after Sept. 7th will receive T-Shirts while supplies last. Race Day Packet Pickup & Late Registration 6:30 - 7:45 am

**ALL Entry Fees and Donations are TAX DEDUCTIBLE**

Pre-registration: $20
Elementary/Middle/High School Students & All Military $15
| Regular
| Registration:
$25
Elementary/Middle/High School Students & All Military $15
Make checks payable to: Hope House of Scott County, Inc
Mail this form to: Hope House of Scott County, Inc.
P.O. Box 1992
Gate City, VA 24251
Headphones are permitted on the course | Strollers are NOT permitted on the course
For more info contact
Laura Quillen
423-418-0604
Break Away 5K Race to End Domestic Violence
Male & Female Awards:

Top Overall
Top Masters
Top GrandMasters

Age Groups (top 3)
...19,20-29,30-39,40-49,50-59,60...

3rd Annual BREAK AWAY 5K Race to End Domestic Violence

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 SHIRT SIZE: SM, MD, LG, XL, XXL

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. STROLLERS ARE NOT ALLOWED ON THE RACE COURSE.

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


This entry form was generated with the SFTC Calendar Utility at www.runtricities.org