Leigh Ann Bolinsky 5k Run/Walk


5k will begin at the Big Stone Gap Visitor Center, follow the Greenbelt Trail, and end back at the starting point. , Big Stone Gap, VA

10/15/2022


Registration opens at 8am. Race starts at 9am.

Pre-registration:
(ends 10/07/2022)
$25> 15 for youth ages 13-18 | Regular
| Registration:
$30
Make checks payable to: MEOC
Mail this form to: P.O. Box 888 Big Stone Gap, VA 24219
Only pre-registered runners are guaranteed a shirt.
Headphones are permitted on the course | Strollers are permitted on the course
For more info contact
Tiffany Jacobs
tiffany.jacobs@meoc.org
276-523-4202
Leigh Ann Bolinsky Memorial 5k Walk/Run
Male & Female Awards:




13 and under, 14-16, 17-19,20-29,30-39,40-49,50-59,60-65, 65+

Leigh Ann Bolinsky 5k Run/Walk

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

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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