USATF#TN03004RH SFTC King & Queen Competition SFTC Long Distance Series Skelton Law Racing Series |
| Pre-registration: (ends 2/19/2011) |
$17 SFTC members receive $2 discount if pre-register | | Regular | Registration: |
$25 No Discounts | |
| SFTC King & Queen race: SFTC members receive preregistration discount | ||||
| Make checks payable to: SURGOINSVILLE 10 MILER | ||||
| Mail this form to: SURGOINSVILLE 10 MILER Law Office of Mark Skelton 121 South Depot Street Rogersville, TN 37857 | ||||
| Scenic out & back certified course on rural roads across & along Holston River Course closes at 2 hours 15 minutes |
| Headphones are NOT permitted on the course | Strollers are NOT permitted on the course |
| For more info contact Mark Skelton 423-345-2335(home) 423-272-4812(office) markskelton@markskelton.com | SURGOINSVILLE 10 MILER Male & Female Awards: Top Overall Top Masters Top GrandMasters Top Sen.GrMasters Age Groups (top 3) ...14,15-19,20-24,25-29,30-34,35-39,40-44,45-49,50-54,55-59,60-64,65-69,70-74,75-79,80... |
| 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) |