ETSU Physical Therapy 5K Run/Walk


The Gazebo at the Veterans Administration Campus, Johnson City, TN , Johnson City, TN

8/8/2009


Registration:7:00am. Race begins at 8:00am

Pre-registration:
(ends 8/1/2009)
$10.00 - preregistration postmarked by 07/28/09. Pre-registered participants are guaranteed a t-shirt! | Regular
| Registration:
Race-day registration - $15.00
Make checks payable to: Stephanie Cline
Mail this form to: Stephanie Cline
1401 West Lakeview Drive
Johnson City, TN 37601
Proceeds will be given to the The Nave Language Center: A Program for Children with Autism and Communication Disorders. . Finish line band-- The Twang Bangers
Headphones are permitted on the course | Strollers are permitted on the course
For more info contact
Stephanie Jeter: zscl2@goldmail.etsu.edu 423-502-9819
ETSU Physical Therapy 5K Run/Walk
Male & Female Awards:




Cash prizes for top male and female overall. Door prizes given away at ceremony!

ETSU Physical Therapy 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,

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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