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Official Entry Form

Town of Floyd 5K Run/Walk

(benefitting Medical Charities of Floyd County, Inc.)

Saturday, August 30, 2014 8:30 a.m.

Please fill out completely. Incomplete forms will not be accepted and will not be entered in the race.

Early 5K Entry (Prior to August 15, 2014) $20.00

5K Entry Fee (August 16, 2015 through 8:15 a.m. race day) - $25.00

First Name ______________________Last Name_______________________________

Address (street, city, state, zip)______________________________________________

______________________________________________________________________

Phone Number___________________ Email Address__________________________

Male ________ Female________ Runner_______ Walker___________

Age on August 30, 2014____________________ Date of Birth__________________

T-shirt Size (S, M, L, XL)____________________

Kids Run - $10.00 T-shirt Size (Youth S, M, L)___________________________

Send entry and fee (made payable to Town of Floyd) to the following address:

Town of Floyd 5K

138 Wilson Street

Floyd, VA 24091

Waiver: In consideration of your accepting this entry, I, the undersigned, intending to be legally bound hereby for myself, my heirs, executors and administrators, waive and release any, and all rights and claims for damages and other claims I may have against the Town of Floyd, Virginia, and its agents, employees, managers and Council members, and all those persons involved in organizing and manning this event from all claims, demands, losses, damages, actions cause of action or suits of whatsoever kind or nature, arising out of my participation in the Town of Floyd 5K on August 30, 2014. I realize that some of the activities may subject me to certain stresses and hazards, not all of which can be foreseen. I desire and consent, by signing this form, to take part in all such activities. I assume all the ordinary risks normally incident to the nature of this activity. Furthermore, I also agree that I have appropriate health care coverage for this activity.

________________________________________________

Signature

________________________________________________

Legal Guardian must sign if entrant is under 18 years old

All entrants must sign this waiver to participate.


  
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138 Wilson Street • Floyd, Virginia  24091 • 540-745-2565

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