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Change a Life 5K Entry Form
June 21, 2008 -- 8:00am --
Heber Springs, AR |
Name:
Last:
First: |
Date of Birth:
Sex: M F
Age on 6/21/08: |
Address: |
City, State, Zip: |
Shirt Size:
S
M
L
XL
|
|
Circle One:
Run Walk
|
Release:
I know that running and volunteering to work in club races are
potentially hazardous activities. I should not enter and run in this
race unless I am medically able and properly trained. I agree to abide
by any decision of a race official relative to my ability to safely
complete the run. I assume all risks associated with running and
volunteering to work in club races including, but not limited to falls,
contact with other participants, the effects of the weather, including
high heat and/or humidity, the conditions of the road and traffic on the
course, all such risks being known and appreciated by me. Having read
this waiver and knowing these facts, and in consideration of your
accepting my entry, I, for myself and anyone entitled to act on my
behalf, waive and release the Change a Life 5K, the city of
Heber Springs, ArkansasRunner.Com, and all sponsors, their representatives
and successors from all claims or liabilities of any kind arising out of
my participation in the race and/or club activities even though
liability may arise out of negligence or carelessness on the part of the
persons named in this waiver. I grant permission to all the
foregoing to use any photographs, motion pictures, recordings, or any
other record of this event for any legitimate purpose. |
Signature:
Date: |
Parent Signature if under 18 years:
Date: |
|
Make checks payable to Heather Curry and mail to:
Change a Life 5K
c/o Heather Curry
P. O. Box 1493
Heber Springs, AR 72543
|
Fees:
$20 if received by
June 1, $25 day of
race
Spirit Runner $10
Teams (at least 15 people signing up together) $15 pre-registered, $20 day
of race
For
information, call 870-213-6880 |
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