3:15pm 1 Mile Fun Run |
| Pre-registration: (ends 2/19/2010) |
$27- 5K $10- Fun Run | | Regular | Registration: |
$30- 5K $10- Fun Run | |
| Make checks payable to: Park Ridge Hospital Foundation | ||||
| Mail this form to: Park Ridge Hospital Foundation Attn: Duncan Sharrits PO Box 1569 Fletcher, NC 28732 | ||||
| Only preregistered runners are guaranteed a Shirt Park Ridge Hospital Employees & family $7 discount |
| Headphones are permitted on the course | Strollers are permitted on the course |
| For more info contact Duncan Sharrits 828-681-2162 | 5K Male & Female Awards: Overall (top 2) Top Masters Age Groups (top 3) ...10,11-15,16-20,21-25,26-30,31-35,36-40,41-45,46-50,51-55,56-60,61-65,66-70,70... |
| 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: YM, YL, SM, MD, LG, XL, |
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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) |