American Cancer Society 5K Registration Form
Saturday, March 3, 2018 8:30 am
9400 Club Hill Drive, Raleigh, NC 27617
Entry Fee: $30/person by February 3, 2018 or $35/person after February 3, 2018 and on race day. (Cash or credit) Register online at www.runnc.com. Late registration participants are not guaranteed to receive a t shirt. All net proceeds go to the American Cancer Society.
Name:______Age:_____ Sex: _____
Street Address______
City______ST____ZIP______
Phone #:______Birthdate___/___/___ Email: ______
Shirt Size: Adult XS S M L XL XXL
Emergency contact Name ______Phone #______
Location of race start and finish: Brier Creek Country Club, 9400 Club Hill Drive, Raleigh, NC 27617
Additional information and volunteer opportunities are available by emailing Adrian Fleming (Brier Creek Fitness Director) at
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