Leigh Ann Bolinskey Memorial 5K Run/Walk


Big Stone Gap Visitor Center, Big Stone Gap, VA

12/11/2021


5:00 pm registration, 6:00 pm race

Pre-registration:
(ends 11/26/2021)
$25 for pre-registered runners
$15 for children ages 13-18
Free for children 12 and under
| Regular
| Registration:
$30 for race-day registration
$15 for children ages 13-18
Free for children 12 and under
Make checks payable to: MEOC/MLCC
Mail this form to: MEOC, Attn: Dianne Morris, P.O. Box 888, Big Stone Gap, VA 24219
Headphones are permitted on the course | Strollers are permitted on the course
For more info contact
Dianne Morris, dianne.morris@meoc.org, 276-523-4202
Leigh Ann Bolinskey Memorial 5K Run/Walk
Male & Female Awards:

Overall (top 3)
Masters (top 3)
GrandMasters (top 3)

Age Groups (top 3)
13 and under, 14-16, 17-19, 20-29, 30-39, 40-49, 50-65, 65+

Leigh Ann Bolinskey Memorial 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, 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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