NCH Heart-One Cardiac Rehab 5K Run


L. F. Addington Gym, Wise, VA

10/14/2017


Registration begins 8:00 A.M.
Race start 9:00 A.M.

Official race shirt is guarnteed to all preregistered runners. Remaining runners will receive a shirt as supply lasts.

Pre-registration:
(ends 10/7/2017)
$25.00
$23.00 (SFTC)
| Regular
| Registration:
$30.00 all runners
SFTC King & Queen race: SFTC members receive preregistration discount
Make checks payable to: Mountain States Rehab
Mail this form to:
Mountain States Rehab
1490 Park Avenue Ste. 1
Norton, Va 24273
NCH\DCH Team Challenge for employees of Norton Community Hospital and Dickenson Community Hospital ONLY. Teams will consist of 5 members. Entry forms for all team members must be submitted together.
Headphones are permitted on the course | Strollers are permitted on the course
For more info contact
Steve Childers (276) 439-1452
NCH Heart-One Cardiac Rehab 5K
Male & Female Awards:

Overall (top 3)
Top Masters
Top GrandMasters
Top Sen.GrMasters

Age Groups (top 3)
...10, 11-13, 14-16, 17-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-79, 80+

NCH Heart-One Cardiac Rehab 5K Run

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,

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)


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