#SuziStrong 5K

5K Run/Walk

Saturday, November 5, 2016

9:00 am

Race Location: Manchester High School.  Cross Country/Field Hockey location.  On-site Registration begins at 8:00 am.

Course Description: 5K Trail/Pavement

Proceeds: All Proceeds to Suzi Burnside and her family.  

Entry Cost information: $30 includes T-shirt.  Register by 10/22 to ensure correct shirt size.

Make Checks to: Suzi Burnside Benefit Donation Fund.  Mail to: 16307 Midnight Xing  Moseley, VA 23120

Contact:  SuziStrong5K@gmail.com

PLEASE PRINT LEGIBLY

Name_________________________________________________________Age______

Address ________________________________________________________________

Phone ___________________________    E-mail _______________________________

SHIRT SIZE (circle One)           SM             M            L           XL           NONE

Waiver (MUST BE SIGNED)

In consideration of your accepting this entry,I, the below signed, intending to be legally bound, for myself, my heirs,my executors and administrators, waive and release and any all rights and claims for damages I may have against the race, and sponsors and their representatives, successors and assigns for any and all injuries suffered by me in said event. I attest that I will participate in this event as a footrace, that I am physically fit and sufficiently trained for the completion of this event. Furthermore, I hereby grant full permission to use my name and likeliness, as well as any photographs and any record of this event in which I may appear for any legitimate purpose, including advertising and promotion.

Signature_______________________________________________Date_________________

Parent or Guardian if under 18__________________________________________________

No refunds will be issued for any reason