Mendota 5k River Run Registration Form printable pdf download

Mendota 5K River Run Registration Form

March 12, 2016

Mendota, Virginia

Schedule

Registration Fees

9 a.m. 5K

5K Pre-Registration (before March 1, 2016)

$20

9:15 a.m. One Mile Walk

5K SFTC Registration

$20

10:30 a.m. Awards

5K Regular Registration

$25

One Mile Walk Registration

$10

Awards

Overall, Top Masters, Top Grand Masters

* Plenty of door prizes * Headphones permitted on course *

Age Groups: 12U, 13–16, 17–20, 21–25, 26–30, 31–35,

Strollers permitted on course * Franklin Track Club King and

36–40, 41–45, 46–50, 51–55, 56–60, 61–65, 66–70, 70+

Queen Event.

All awards are for Top 3 placing. Male and female awards.

For more info, contact Wayne at pitonina@bvu.net

Circle Your Event and Shirt Size

5K Run / One Mile Walk | T-Shirt Size: S, M, L, XL, XXL

Provide Your Details

Last Name: ______________________________ First Name: ______________________________ Middle Initial: ______

Sex (circle): M / F Date of Birth: ______________________________ Age on Race Day: ________

Email: ______________________________ Telephone: (

)

Address: ____________________________________________________________________________________________

City: _____________________________________________________ State: __________ Zip: _____________________

Race Day Emergency Contact (Name and Phone): ___________________________________________________________

Sign Application and Waiver

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 UNDER-

STAND MY OWN LIABILITY AND ABILITY.

Signature: ________________________________________________________ Date: ______________________________

Note: If participant is under age of 18, parent must provide signature.

Send Payment

Make checks payable to: Mendota Community Association

Mail this form with payment to:

MCA/care of Wayne Hays

2567 Mendota Rd

Mendota, VA 24270

Mendota 5k River Run Registration Form

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