Grundy Kiwanis/Trupoint Bank 5K Run


Grundy Community Center Theatre, Grundy, VA

5/3/2014


9am - 5K Run

Pre-registration:
(ends 4/28/2014)
$15 - 5K | Regular
| Registration:
$15 - 5K
Make checks payable to: Grundy Kiwanis
Mail this form to: Grundy Kiwanis
PO Box 724
Grundy, Va. 24614
Only preregistered runner are guaranteed a tshirt
Pancake breakfast after run
Headphones are permitted on the course | Strollers are permitted on the course
For more info contact
Ricky Owens or Jon Rife
(276)935-2181
rickyowens@rifestv.net
5K Grundy Run
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...

Grundy Kiwanis/Trupoint Bank 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)


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