8am - 5K Run |
| Pre-registration: (ends 06/28/13) |
$20 - 10K Run $20 - 5K Run | | Regular | Registration: |
$25 - 10K Run $25 - 5K Run Race Day Registration | |
| Make checks payable to: Young Life | ||||
| Mail this form to: YoungLife Heritage Classic, 615 W. Main Street, Tazewell, VA 24651 | ||||
| Only pre-registered guaranteed a t-shirt! |
| Headphones are permitted on the course | Strollers are permitted on the course |
| For more info contact Brad Pyott H:(276) 988-4651 C:(276) 971-7854 O: (276) 988-5525 fbp26run@verizon.net | 10K Run Male & Female Awards: Overall (top 3) Age Groups (top 3) ...14,15-19,20-24,25-29,30-34,35-39,40-44,45-49,50-54,55-59,60... | 5K - YoungLife Heritage Classic Male & Female Awards: Overall (top 3) Age Groups (top 3) ...14,15-19,20-24,25-29,30-34,35-39,40-44,45-49,50-54,55-59,60... |
| 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)_________________________________________ |
*** CIRCLE EVENT: 10K Run | 5K - YoungLife Heritage Classic |
*** CIRCLE SHIRT SIZE: SM, MD, LG, XL, |
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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. |
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SIGNATURE_____________________________ DATE_____/_____/_____ (Parent signature if under the age of 18) |