| Pre-registration: (ends 3/19/2010) |
$12 | | Regular | Registration: |
$15 Same day race registration is available | |
| SFTC King & Queen race: SFTC members receive preregistration discount | ||||
| Make checks payable to: ETSU Take Back the Night | ||||
| Mail this form to: ETSU Counseling Center Rebecca Alexander PO Box 70724 Johnson City, 37614 | ||||
| $1 discount to SFTC members |
| Headphones are permitted on the course | Strollers are permitted on the course |
| For more info contact Rebecca Alexander at 439-4841 or OASIS@etsu.edu | Take Back the Night 5K Male & Female Awards: Top Masters Top GrandMasters Age Groups (top 3) ...19,20-24,25-29,30-34,35-39,40-44,45-49,50-54,55-59,60... |
| 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, |
|
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) |