11AM - 1.5 MILE RUN(5TH GRADE - 8TH GRADE) |
| Pre-registration: (ends 9/29/2012) |
$12 - 5K RUN | | Regular | Registration: |
$15 - 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... |
| 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, |
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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. |
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SIGNATURE_____________________________ DATE_____/_____/_____ (Parent signature if under the age of 18) |