Pre-registration: (ends 10/05/2023) |
$35 (Jan. 1, 2023-April 30, 2023) $40 (May 1, 2023-July 31, 2023) $45 (August 1, 2023-Oct. 7, 2023) | | Regular | Registration: |
$45 Race Day Registration | |
Make checks payable to: The Clinch Coalition | ||||
Mail this form to: The Clinch Coalition, C/O Katie Dunn, P.O. Box 2732, Wise, VA 24293 |
Headphones are permitted on the course | Strollers are NOT permitted on the course |
For more info contact Katie Dunn, highknobhellbender@gmail.com, 770-654-3942 | High Knob Hellbender 10K Male & Female Awards: Overall (top 3) Top Masters Age Groups (top 3) 29 and Under; 30-39; 40-49; 50-59; 60-69; 70 and over |
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. STROLLERS ARE NOT ALLOWED ON THE RACE COURSE. |
SIGNATURE_____________________________ DATE_____/_____/_____ (Parent signature if under the age of 18) |