POSTPONED UNTIL APRIL - 6th Annual Break Away 5K Race To End Domestic Violence


Gate City, VA, ,

11/4/2017


8:30 am

This annual event is organized by Hope House of Scott County, Inc. in an effort to raise awareness about domestic violence and sexual assault. All proceeds go to support Hope House of Scott County, Inc.

*All registered participants will be entered into a drawing for some great door prizes! The GRAND PRIZE will be a FREE TEMPUR PEDIC MATTRESS donated by Tempur Productions.

**ALL Entry Fees and Donations are TAX DEDUCTIBLE**
  • Results


  • Pre-registration:
    (ends 10/28/2017)
    $20
    $15 All Active/Retired Military, First Responders, Elementary, Middle, High School Students
    | Regular
    | Registration:
    On or after 10/29/17
    $25
    $15 All Active/Retired Military, First Responders, Elementary, Middle, High School Students
    Make checks payable to: Hope House of Scott County, Inc
    Mail this form to: P.O. Box 1992
    Gate City, VA. 24251
    This is the 6th Annual Break Away 5K Race To End Domestic Violence. All proceeds go to support Hope House of Scott County, Inc. Race Day Packet Pickup & Late Registration 9:00 - 9:45 a.m.

    **ALL Entry Fees and Donations are TAX DEDUCTIBLE**
    Headphones are NOT permitted on the course | Strollers are NOT permitted on the course
    For more info contact
    Laura Quillen 423-418-0604 - hopehousebreakaway5k@gmail.com
    www.facebook.com/hopehousebreakaway5k
    5K
    Male & Female Awards:

    Top Overall
    Top Masters
    Top GrandMasters
    Top Sen.GrMasters

    Age Groups (top 3)
    1-8,9-13,14-19,20-29,30-39,40-49,50-59,60+

    POSTPONED UNTIL APRIL - 6th Annual Break Away 5K Race To End Domestic Violence

    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. 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)


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