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CASA Champs for Children
Entry Form
October 2, 2010 --
9:00am -- DeWitt, AR |
Name:
Last:
First: |
Date of Birth:
Sex: M F
Age on 10/2/10: |
Address: |
City, State, Zip: |
Shirt Size: YL
S
M
L
XL
XXL(+$2)
XXXL(+$3) |
Email:
Phone: |
Circle One:
5K 1M Fun 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 CASA Champs for
Children 5K,
CASA, the city of
DeWitt, 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 CASA of Arkansas County and mail to:
CASA of Arkansas County
1464 Hwy 276
DeWitt, AR 72042
|
Fees:
Adult: $20 pre-registered, $25 day of
race
For information, 870-946-0080 |
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