Valley Health Care/Iron Mtn Riders 5K Glow Run for ST JUDE CHILDREN'S HOSPITAL


registration begins at the parking area between Valley Health Care Center and the Loaves and Fished Food Bank
, Chilhowie, VA

5/13/2017


Registration from 7:00 pm to 8:15 pm
Race begins at 8:30 pm

Pre-registration:
(ends 05/05/2017)
$20 for adults, $15 for kids | Regular
| Registration:
$25 for adults, $20 for kids
Make checks payable to: VHCC Employee Council, Donations may also be made out to St Jude Children's Hospital
Mail this form to: Valley Health Care Center
P O Box 748
Chilhowie, VA 24319
Only preregistered are guaranteed a tshirt, glow sticks will be provided to each participant
Headphones are NOT permitted on the course | Strollers are NOT permitted on the course
For more info contact
Debbie Blankenship - 276-608-4983
Karla Blevins 276-646-4332
Valley Health Care/Iron Mountain Riders 5K Glow Run
Male & Female Awards:

Overall (top 3)
Top Masters
Top GrandMasters

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

Valley Health Care/Iron Mtn Riders 5K Glow Run for ST JUDE CHILDREN'S HOSPITAL

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: 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. STROLLERS ARE NOT ALLOWED ON THE RACE COURSE. PARTICPANTS USING HEADPHONES ARE NOT ALLOWED ON THE RACE COURSE.

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


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