| Pre-registration: (ends 8/19/21) |
$25 | | Regular | Registration: |
$30 | |
| Make checks payable to: Bristol Regional Speech and Hearing | ||||
| Mail this form to: Bristol Regional Speech and Hearing 359 Commonwealth Ave Suite 100 Bristol, VA 24201 | ||||
| Headphones are permitted on the course | Strollers are permitted on the course |
| For more info contact Elaine Rock, erock@brsh.com | Run Your Mouth 5K Male & Female Awards: Overall (top 3) Top Masters Top GrandMasters Age Groups (top 3) 9 & Under, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70 & Older | 5K Walk - Untimed Male & Female Awards: No awards |
| 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 EVENT: Run Your Mouth 5K | 5K Walk - Untimed |
*** CIRCLE SHIRT SIZE: SM, MD, LG, XL, XXL |
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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. |
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SIGNATURE_____________________________ DATE_____/_____/_____ (Parent signature if under the age of 18) |