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Child Abuse Awareness 5K
Entry Form
April
10, 2010 -- 8:00am --
Pine Bluff Arsenal, AR |
Name:
Last:
First: |
Date of Birth:
Sex: M F
Age on 4/10/10: |
Address: |
City, State, Zip: |
Shirt Size: S
M
L
XL
XXL |
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Circle One: 5K Run
2M Walk
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Release:
I hereby waive and release any and
all rights and claims for damages which I may have against the Pine Bluff
Arsenal, ArkansasRunner.com, as well as
promoters, other participants, operators, officials, any person in a
restricted area, sponsors, advertisers, owners and leasees of premises
used to conduct the event and each of them, their officers and employees,
all for the purposes herein referred to as “releases”, from all liability
to the undersigned, his personal representatives, assigns, heirs and next
of kin for any and all damages and any claim or demands therefore on
account of injury to the person or property or resulting in death of the
undersigned, whether caused by the negligence of the release or otherwise
while the undersigned is in or upon the restricted area, and/or,
competing, officiating in, observing, or working for, of for any purpose
participating in the event. I further agree to hold harmless
ArkansasRunner.com, the
Government, its officers, agents, and employees for any damage to my
personal property or me caused as a result of my participation in this
event. I further understand that I am responsible for all dependents and
authorized guest who accompany me while participating in this event. |
Signature:
Date: |
Parent Signature if under 18 years:
Date: |
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Make checks payable to:
Child Abuse Awareness 5K
Mail to:
Pine Bluff Arsenal
JMPB-PAR (Fitness Center)
Attn: Carla Easterling, Bldg. 16-310
Child Abuse Awareness 5K
Pine Bluff, AR 71602 |
Fees:
$20 pre-registered, $25 day of race
For
information, call 870-540-3588 or 870-540-3779 |
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