| print in portrait format if possible 4th of July Spectacular 5K Run/Walk Official Entry Form Name: ________________________________________________________________________________ Address:_____________________________________________________________________________ City, State, Zip:_________________________________________________________________________ Phone:______________________________________________________ email: ________________________________________________________________@_________________________________ Sex:_____________Age on Race Day:____________ Race Division (check one only): 5K Run _________ 5K Walk_________ Weight Divisions - Optional (5K Run Only - check one only) Clydesdale 1 - Men 200-219_______ (Not eligibable for age group awards) Clydesdale 2 - Men 220+________ (Not eligibable for age group awards) Athena - Women160+_______ (Not eligibable for age group awards) Entry
Fee: (check only one) ________$17 Pre-registration with T-Shirt ________ $15 Race Day (no T-Shirt) ________$22 Race Day (with T-Shirt) T-Shirt size: (circle one if applicable) S, M, L, XL Make
checks payable to: Spectacular 5K WAIVER: In consideration of the acceptance of my entry, I hereby waive, discharge and release on behalf of myself, my heirs, executors and assigns, all claims of any nature, including but not limited to damages, demands, actions, whatsoever in any manner, arising from my participation in the Spectacular 5K, and do hereby release the Spectacular 5K, Running Time, LLC, coordinators, staff, all sponsors, workers, officials and volunteers from any claim whatsoever arising from my participation in this event. I agree to abide by all rules for participation and acknowledge that the Race Committee may refuse or return my entry at its discretion. I attest and verify that I understand the risks involved in such a run/walk, and that I am physically fit and have trained adequately in preparation and I agree to pay for my own medical expenses in the case of an accident or illness regardless of whether I have authorized such expenses. I HAVE NOTED ANY MEDICAL CONDITION on the reverse side of this form. I permit the use of my name and picture participating in this event for publicity. ENTRY SIGNATURE:_____________________________________________Date: __________________ Parent's Signature (if under 18): ____________________________________Date: ___________________ Emergency Contact: __________________________________________Phone________________________ |