Bill Gatton College of Pharmacy Apothecary Dash 5k


Veteran's Affairs Campus, Johnson City, TN

3/28/2015


Registration begins at 9 am
Race begins at 10 am
**All proceeds benefit Relay For Life and the American Cancer Society**

Make checks payable to: Kappa Psi Pharmaceutical Fraternity
Mail this form to: 2914 S Greenwood Dr. #11
Johnson City, TN 37604
If you have any questions please contact Morgan Corbin at corbinmm@goldmail.etsu.edu
Headphones are permitted on the course | Strollers are permitted on the course
For more info contact
email: dedicb@goldmail.etsu.edu
Apothecary Dash 5k
Male & Female Awards:

Overall (top 3)
Masters (top 3)
GrandMasters (top 3)

Age Groups (top 3)
...19,20-24,25-29,30-34,35-39,40-44,45-49,50-54,55-59,60...

Bill Gatton College of Pharmacy Apothecary Dash 5k

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 SHIRT SIZE: 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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