NCH Heart-One Cardiac Rehab 5K Run


L. F. Addington Gym, Wise, VA

10/13/2018


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. Preregistered runners will have a choice between a cotton/polyester blend shirt or a technical shirt. There will be no difference in price and this option is ONLY available to preregistered runners. Registrants will need to write "tech" or "blend" beside shirt size on their entry form. Those who make no choice will be given a blend shirt.

Pre-registration:
(ends 10/6/2018)
$25.00
$24.00 (SFTC)
| Regular
| Registration:
$30.00
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
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 Run
Male & Female Awards:

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

Age Groups (top 3)
...9, 10-14, 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75-79, 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)_________________________________________

*** 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