| Pre-registration: (ends 11/11/22) |
$25 by 11/11/22 | | Regular | Registration: |
$35 11/12 and 11/13 | |
| Make checks payable to: West Side Elementary School PTO | ||||
| Mail this form to: West Side Elementary School PTO 1310 Burgie Street Elizabethton, TN 37643 | ||||
| Headphones are permitted on the course | Strollers are permitted on the course |
| For more info contact Danielle Back, danielleg586@aol.com, 423-483-2070 | 5K Run/Walk Male & Female Awards: Top Overall Age Groups (top 3) 6 under, 7-9, 10-12, 13-15, 16-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70 over | I Mile Fun Walk (Untimed) Male & Female Awards: Age Groups (top 3) No awards |
| 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 EVENT: 5K Run/Walk | I Mile Fun Walk (Untimed) |
*** CIRCLE SHIRT SIZE: SM, MD, LG, XL, XXL |
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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) |