BREAKS PARK 5K CROSS COUNTRY RUN


BREAKS PARK, Breaks, VA

10/4/2014


10AM - 5K RUN (OPEN & HIGH SCHOOL)
11AM - 1.5 MILE RUN(5TH GRADE - 8TH GRADE)

Pre-registration:
(ends 9/27/2014)
$15 - 5K RUN | Regular
| Registration:
$20 - 5K RUN
Make checks payable to: GRUNDY KIWANIS
Mail this form to: GRUNDY KIWANIS
PO BOX 724
GRUNDY, VA. 24614
$150 1ST PLACE HIGH SCHOOL TEAM MALE & FEMALE
$100 2ND PLACE HIGH SCHOOL TEAM MALE & FEMALE
$75 3RD PLACE HIGH SCHOOL TEAM MALE & FEMALE
ONLY PREREGISTERED RUNNERS ARE GUARNTEED A SHIRT
PANCAKE BREAKFAST
Headphones are NOT permitted on the course | Strollers are NOT permitted on the course
For more info contact
JON RIFE OR RICKY OWENS
(276)935-2181
JONRIFE@RIFESTV.NET
BREAKS PARK/KIWANIS 5K
Male & Female Awards:

Top Overall
Top Masters
Top GrandMasters
Top Sen.GrMasters

Age Groups (top 3)
...14,15-19,20-24,25-29,30-34,35-39,40-44,45-49,50-54,55-59,60...

BREAKS PARK 5K CROSS COUNTRY 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. 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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