American Cancer Society 5K Registration Form
Saturday, March 11, 2017 8:30 am
9400 Club Hill Drive, Raleigh, NC 27617
Entry Fee: $30/person by February 11, 2017 or $35/person after February 11, 2017 and on race day.
Register online at www.runnc.com.
Late registration participants are not guaranteed to receive a tee shirt. All net proceeds go to the American Cancer Society.
Name:__________________________________________________________
Street Address___________________________________________________
City__________________________________State___ Zip_______________
Phone #:______________ Age:_____ Sex: M F Birthdate____/______/____
Shirt Size: Adult XS S M L XL XXL
Contact Email: ___________________________________________________
Emergency contact information: _________________________________________
Name Phone number
Location of race start and finish: Brier Creek Country Club, 9400 Club Hill Drive, Raleigh, NC 27617
Please make checks payable to Brier Creek Country Club. Entry form and checks may be mailed to the above address. Additional information and volunteer opportunities are available by calling Adrian Fleming (Fitness Director) at 919-206-4693 or email
I, ___________________________, fully understand and hereby consent to participate in the Brier Creek Country Club American Cancer Society 5K. I have been informed and understand that physical exercise has been associated with certain risks, including but not limited to musculoskeletal injuries, spinal injuries, abnormal blood pressure responses, and, in rare instances, heart attack or death. I have read and understand the foregoing consent to participate in the Brier Creek Country Club American Cancer Society 5K. I also understand that I may stop the race at any time.
In addition, I agree to the following:
· Assume all risk of injury and all risk of damage to or loss of property arising out of my participation in this race.
· Release, discharge and waive any and all responsibility of the Brier Creek Country Club, American Cancer Society 5K organizers, American Cancer Society 5K sponsors, Young and Associates and Toll Brothers Inc. against all liability of injury, including death, and for damage to or loss of property which may be suffered by the undersigned arising out of, or my participation in the Brier Creek Country Club American Cancer Society 5K.
· This event is being timed and scored by Young and Associates. On race day, participants will be required to pick up a timing chip at least 1/2 hour prior to the start. Failure to wear a timing chip during the event will prevent the participant from being timed. At the finish line, all timing chips must be returned to Young and Associates or the participant will be charged $20.00.
· I give Toll Brothers, Inc. and Brier Creek Country Club permission to use my picture in print and internet marketing. _____ YES ____ NO
· No refunds will be issued for any reason.
*If under 18 years of age, parent/guardian signature is required.
________________________________ _____________________________ ____________
Printed Name Signature Date