Chruch Hill Medical Mission 5 K Flamingo Race


Derrick Park, Church Hill , TN

8/26/2017


7. A.M. Registration
8 A.M. Race startes

Pre-registration:
(ends September 1 ,2016)
$25 Pre-registration before September 1, 2017 | Regular
| Registration:
$30 Registration
Make checks payable to: Church HIll Medical Mission
Mail this form to: P.O. Box 166
Church Hill, Tn 37642
Headphones are permitted on the course | Strollers are permitted on the course
For more info contact
Tammy Brown-tambra196344@outlook.com
Teresa Tilson - tereastilson1957@gmail.com
Phone: 423-256-2408
Church Hill Medical Mission 5K Flamingo Race/Walk
Male & Female Awards:

Top Overall
Top Masters
Top GrandMasters
Top Sen.GrMasters

Top Age Groups
...19,20-28,29-37,38-46,47-55,56-64,60...

Chruch Hill Medical Mission 5 K Flamingo Race

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, 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.

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


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