Young Life 5K Community Splatter RUN/WALK
Saturday, May 10, 2014
REGISTRATION
First Name______
Last Name______
Address:______
City, State, ZIP:______
Email Address: ______Phone #: ______
In case of Emergency, Please Contact: ______Phone #: ______
Male_____ Female_____ My age group is ____0-13 ____14-19 ____20-39 ____40 and above
Entry Fees: Adult - $25 or $30 day of event; Teen - $20; Child (0-13) - $10
Register by April 23rd and receive a “free”5K T-Shirt
Proceeds to benefit
Registration Time -9:00am at Emerald Hill Elementary School parking lot.(Not sponsored by CCPS)
5K Run/Walk (Muddy Run Road) begins at 9:30am– 11:00am
Event Description: Join us for the second annual tradition of the Young Life Community 5K
Splatter Run/Walk. Enjoy being splattered (non toxic, water based) at different points during the
race, and participate in the color throw "free for all" at the end. Wear clothes that can get messy
(color does wash out). Awhite tee shirt will allow color to show up well. Color packetsprovided.
I know that running a road race is potentially hazardous activity. I should not enter and run unless I am medically able and properly trained. I also know that
although it is unlikely, there may be traffic on the course route and I must watch for vehicles at intersections and on the roads. I also assume any and all other
risks associated with running this event including but not limited to falls, contact with other participants, the effects of weather including high heat and/or
humidity and the condition of the roads. I recognize wearing a portable listening device during the race is prohibited by the organizers.
Knowing these facts, and in consideration of your acceptance of my entry fee, I hereby for myself, my heirs, executors, administrators or anyone else who might
claim on my behalf, covenant not to sue, and waive, release, and discharge The Young Life Community 5k, Young Life Culpeper and any organization associated
with the race, and the local governments and police, volunteers, and any and all sponsors including their agents, employees, assigns or anyone acting on their
behalf, from any and all claims or causes of action (known or unknown, foreseen or unforeseen) for death, personal injury or property damage of any kind or
nature including those arising out of, their negligence in the course of, my participation in this road race and all other events and activities associated with this
race.
I give my permission for medical team evaluation, treatment, and transfer to an emergency facility if needed. I agree that race officials have the right to
remove me from the race and related activities if they are of the opinion that it is in my best interest or the best interest of the Young Life Community 5K that
I beremoved. I further grant permission to the Young Life Community 5K and/or agents authorized by them to use any photographs, videotapes, motion
pictures,recordings, or any other record of this event for any purpose without limitation or compensation. I understand that fees are not refundable and race
numbersand timing chips (if applicable) are not transferable.
I have read the foregoing and certify my agreement by signing below. (Parent or guardian must sign below if applicant is under 18 yrs old).
SIGNATURE OF PARTICIPANT (Or signature of parent/guardian if participant is under 18 years old):
______PRINT NAME: ______
Registration fee enclosed:$______
CircleT-Shirt size: Adult- S M L XL XXL Youth - S M L
I wish to make an additional donation in the amount of$______
TotalAMOUNT ENCLOSED: $______
Mail check (payable to YoungLife and/or Safe) to P.O. Box 803, Culpeper, VA 22701
Young Life Culpeper Culpeper.younglife.org (540) 219-8043
SAFE Safejourneys.org(540) 825-8891