Join in the fun ~ sign up & wear a festive costume or anything Green! Celebrate the St. Patrick’s Day holiday at Coaltown Taps after the race with live music - Let's ROCK! All proceeds and donations benefit St. Jude Children's Research Hospital. |
| Pre-registration: (ends 03/05/2022) |
5K Run/Walk Pre-registered (March 5): $25.00 Under 18 Pre-registered (March 5): $20.00 Virtual 5K Run - $25.00 | | Regular | Registration: |
5K Run/Walk March 6 - March 19: $30.00 Under 18 March 6 - March 19: $25.00 Virtual 5K Run - $25.00 | |
| Make checks payable to: Soles4Services, Inc. | ||||
| Mail this form to: PO Box 285, Tazewell, VA 24651 | ||||
| Headphones are NOT permitted on the course | Strollers are NOT permitted on the course |
| For more info contact Charity Hurst cdhurst17@gmail.com | ShamROCK'N 5K Male & Female Awards: Overall (top 3) 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... |
| 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, 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. 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) |