Smyth County Fuller Center 5K Fun Run/Walk

-WEBSITE-
Marion Baptist Church
1258 N. Main Street
Marion, VA 24354
Marion,VA
5/9/2009
Registration 8 a.m.
Race 9 a.m.
Pre-registration:
(ends 5/2/2009)		 $15 with Race T-Shirt
$10 without Race T-Shirt		 | Regular
| Registration:		 $15 with Race T-Shirt
$10 without Race T-Shirt
$100 - 1st Place Overall Male
$100 - 1st Place Overall Female
Mail this form to:
Smyth County Fuller Center 5K
249 Thomas Heights
Marion, VA 24354
Make checks payable to
Smyth County Fuller Center
For more info contact
Neil Castrodale
(276)783-7537 		Smyth County Fuller Center 5K Fun Run/Walk
Male & Female Awards:
Top Overall

Top Age Groups
...14,15-19,20-29,30-39,40-49,50-59,60+
Smyth County Fuller Center 5K Fun Run/Walk

LAST NAME___________________________ FIRST NAME________________________ M.I.______

SEX____ DATE OF BIRTH____/____/____ AGE ON RACEDAY______ PHONE (_____)_____-_______

ADDRESS_________________________________________________________________________

CITY________________________________________________ STATE______ ZIP______________

E-MAIL___________________________________________________________________________

RACE DAY EMERGENCY CONTACT (NAME AND PHONE)___________________________________

__________________________________________________________________________________

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. DUE TO INSURANCE REGULATIONS, STROLLERS AND HEADPHONES ARE NOT ALLOWED ON THE RACE COURSE.

SIGNATURE______________________________________________ DATE________________
(Parent signature if under the age of 18)

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