Smyth County Fuller Center 5K Fun Run/Walk


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
Make checks payable to: Smyth County Fuller Center
Mail this form to: Smyth County Fuller Center 5K
249 Thomas Heights
Marion, VA 24354
$100 - 1st Place Overall Male
$100 - 1st Place Overall Female

Headphones are permitted on the course | Strollers are permitted on the course
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_____ 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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