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Team name   First name   Last name   Email address   Age on event date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Gender -- Male Female   Emergency contact name   Emergency phone #   Event entry fee 25.00 USD

T-shirt size None Small Medium Large Extra large

Discount or coupon code   Subtotal 25.00 USD Discount 0.00 USD Total 25.00 USD Calculate

Please review the waiver provided by the event organizer and click the check box below to accept it. Print waiver I know that running or walking a road / trail race is a potentially hazardous event, and I should not enter and run or walk unless I am medically able and properly trained to do so. I agree to abide by any decision of any race official relative to my ability to safely complete the run or walk. I assume all risks associated with running or walking in this event, including, but not limited to : falls; contact with other participants; the effects of weather, including high heat, humidity, or cold; traffic; the conditions of the road / trail; and all such other risks being known and appreciated by me. Having read this waiver, and knowing these facts and in consideration of acceptance of entry, I, for myself and anyone entitled to act on my behalf, do hereby waive and release Stonewall Jackson Memorial Hospital, Pace Yourself Lewis County, and any and all additional sponsors and their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event, even though that liability may arise out of negligence or carelessness on the part of the persons named herein. I grant permission to all of the foregoing to use any photographs, motion pictures, records or any other documentation of this event for any and all legitimate purposes. This event will be held without regard to weather conditions. Registration is final and no refunds will be issued for any reason. I accept the terms of the waiver Name of parent or guardian who approves this activity Please enter your name here