| Pre-registration: (ends 4/5/2010) |
$5 You can also sign up @ the store. | | Regular | Registration: |
No race day registration! | |
| Make checks payable to: Foot Rx | ||||
| Mail this form to: 3135 Peoples St Suite 404 Johnson City,TN 37604 | ||||
| No shirts! |
| Headphones are permitted on the course | Strollers are permitted on the course |
| For more info contact Steve @ 423 282 2235 www.footrxjc.com | Foot Rx Flippin Fast Mile Male & Female Awards: Top Overall Top Masters Top Age Groups 9 & under, 10-12,12-14,15-19,20-29,30-39,40-49,50 & older |
| 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)_________________________________________ |
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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) |