4th Annual

COATES BEND VOLUNTEER FIRE AND RESCUE 5K BENEFIT RUN/WALK April 6th 2013 @ 6pm

(At Night)

Race Day Registration and Packet Pickup: 4pm– 5:30pm Race Begins: 6pm

QUESTIONS?? Email:

Early Entry Fee: $15_____ (After 12/31/2012) Entry Fee: $20_____(GRC Members get $2 discount)

Race Day Fee: $25 ______(Pre-registration fee includes T-Shirt, coupons and refreshments)

Mail to: Attn: Jeff Morris, CBVFD 1140 Pulltight Road, Gadsden, AL35901

Make checks payable to CBVFD. (Please DO NOT MAIL CASH)

Awards will be given to the top 3 in each division.

Shirts areONLY guaranteed to those who PRE-REGISTER. Race day registrationis not guaranteed a shirt.

You may register by mail or through and searchCBVFD 5K Run.

Packet pick-up & On-Site Registration will be the day of the Race from 3pm to 4:30. No pets please.

First Name:______MI:______Last Name:______

Address:______City:______State:______Zip:______

Gender: Male or Female DOB:____/_____/______Age:______

Email:______Phone: (______)______

Emergency Contact:

Name: ______Phone Number: (____)______Relationship______

GRC Member: Yes______No______If Not would you like info?______

T-Shirt Size: YS YM YL S M L XL XXL XXXL

This release must be signed by each participant or the parent/guardian of each participant: I know that running a road race is a potentially hazardous activity. I should not enter and run the Coates Bend Fire & Rescue 5K run unless I am medically able. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all responsibilities and risks associated with running the event including but not limited to falls, contact with other participants, the effects of weather including high heat/ and or humidity, traffic and conditions of the road including death. All such risks are known and appreciated by me. Having read this waiver and knowing the risks and in consideration of you accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release Coates Bend Fire & Rescue, The City Of Gadsden, all volunteers, sponsors, together with their employees, contractors, subcontractors, directors, officers, agents, attorneys, representatives, and successors from all claims of liabilities of any kind or character arising from my participation in this event.

I HEARBY AFFIRM THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER, I HAVE READ THIS DOCUMENT, AND I UNDERSTAND ITS CONTENTS.

PRINT NAME:______SIGNATURE OF APPLICANT:______

DATE:______

(Under 18 years of age)

I HAVE READAND UNDERSTAND THIS WAIVER AND RELEASE AGREEMENT SHALL BIND ME, MY CHILD, OUR PERSONAL REPRESENTATIVES, HEIRS AND ASSIGNS. I HEARBY RELEASE AND PROMISE NOT TO SUE, AND SHALL DEFEND, INDEMNIFY AND HOLD HARMLESS, THE RELEASE FROM EVERY CLAIM AND ANY LIABILITY that I or my child may allege against the Releases, including attorney fees, as a direct or indirect result of injury to me or my child, or my child’s property, or resulting in my child’s death, because of my child’s participation in the event or staging, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASES or otherwise. For persons under 18 years of age, a parent or legal guardian must sign this waiver and Release.

PARENT/GUARDIAN SIGNATURE______Relationship______Date______