2017Run for Cystic Fibrosis

5 kilometer road race

Saturday, April 22nd, 2017- Lake Village, Arkansas

Lake chicot state park – OUTDOOR PAVIlion #2

Start and Finish: This is a point to point race. Participants will need to park near the outdoor pavilion near swimming pool. This is the finish line area. You will be bussed to the start line down Highway 144 just east of the state park. The 5K (3.1 miles) course will run down Highway 144 towards the state park and then loop thru the park before ending at the outdoor pavilion #2

Fee: $20 for those 13 years and older and $10 for those 12 years and younger for those registered by Friday, April 14th. Fee will increase to $25 on Saturday, April 15th and shirts will not be guaranteed for those registering after Friday, April 14th. Please register early.

Registration: Please fill-out and detach the bottom of this form and drop off cash or check payable to LVA at the Lake Village Chamber of Commerce office at 111 Main St, Lake Village, AR 71653 or mail the form to P.O. Box 1004, Lake Village, AR 71653 or register at LVAchurch.com. $25 race day registration will run from 7:30am – 8:30am at Outdoor Pavilion #2.

Packet Pick-Up: Packet pick-up will start on Friday, April 21st from 5:00pm to 7:00pm at Lake Village Assembly at 150 Lynn Lane behind McDonalds. Packet pick-up will also take place from 7:30am to 8:40am at the outdoor pavilion. Shuttles will run from the outdoor pavilion to the start line from 8:15am to 8:40am. The last shuttle will leave at 8:40am as race starts at 9:00am.

Awards: While this is a family fun community event, we will provide awards to Overall and Age Group winners. The top three male and females overall and top three male and female in each respective age group will receive awards at the awards ceremony following the completion of the event. The age group awards are as follows for both male and female: 19Under, 20 – 29, 30 – 39, 40 – 49, 50 – 59, and 60 & Up. FOR ANY MORE INFORMATION PLEASE CONTACT RACE DIRECTOR JOHN CONNER AT
Last Name ______First Name______T-Shirt Size: Circle One
Address______Youth: Small Medium Large
City______State______Zip______Adult: Small Medium Large
Phone______Email______X Large XX Large
Date of Birth____/____/______Gender Male______Female______Strollers/Baby Joggers allowed, but please start near back!!!

Waiver: I hereby declare, assert and affirm that participation in the Lake Chicot Fall Festival 5K Run/Walk is done having voluntarily and knowing assumed ALL RISKS involved in this event. The immediate physical risks and hazards associated with normal, vigorous physical activity include (but are not limited to) physical discomfort, fatigue, muscular soreness, falls, pulled or strained muscles, overuse injuries, heat stress, and the rare instance of abnormal responses of the cardio-respiratory system including heart arrhythmia, heart attack, stroke, and sudden death. In consideration of acceptance of this contract allowing my participation in the above stated Special Event and intending to be legally bound thereby, I hereby for myself, my heirs, executors, administrators and assigns, WAIVE AND RELEASE any and all rights and claims for negligence, injuries, damages or losses that I may incur against all participating agencies involved in the above stated Special Event, specifically Lake Village Chamber of Commerce, the City of Lake Village, event sponsors, their respective employees, agents, representatives, successors and assigns, for any and all activities connected with the above Special Event. I also understand that I do hereby WAIVE any and all rights or benefits under the State of Arkansas Worker's Compensation laws for any injury incurred as a result of my participation in this event, including disregard of theposted route.

Print Name______Date ______
Signature______Parent/Legal Guardian must sign if participant is under the age of 18