Heart For Haiti 5K

October 29, 2016 at 10:00 AM

Warriors Path State Park, Kingsport, Tennessee
$25.00 Fee Includes T-Shirt
Male & Female Awards
Age Groups (Top 2)
18 & Under - 19-35 - 36-50 - 50 & Over
Make Checks Payable to Ragged Edge Ministries
Mail this form to:
Norma Mullins
332 Wonderland Drive
Kingsport, TN 37660

For more information contact Norma Mullins or Bill Mullins at 423-384-6175

Last Name________________________ First Name_______________________ M.I._______

Sex____________________ D.O.B_____________________ Age On Race Day____________

E-Mail______________________________________________________________________
Mailing Address:______________________________________________________________
City____________________________________ State________ Zip_____________________
Phone Number_______________________________________________________________
Race Day Emergency Contact____________________________________________________
Circle Shirt Size: SM, MD, LG, XL, XXL
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 UNDERSTAND MY OWN LIABILITY AND ABILITY.

Signature:___________________________________________________________
(Parent signature if under the age of 18)
Date:_________/_________/_________