I wish to participate in (check one) Half_____5K____
Last Name ____________________________________
First Name____________________________________
Street Address__________________________________________________________
City__________________________________________ State____ Zip Code_______
Phone_____________________E-mail_____________________________
Birth date (mm/dd/yy) ____/____/____ Age on (10/10/09) _____ Sex (circle one) M F
Emergency Contact Name and Phone__________________________________________
Entry Fee:
5K or Half: $25 if postmarked prior to 9/30/09 Enclosed: $ ______
5K or Half: $30 after 9/30/09 Enclosed: $ ______
Liability Waiver and Release:
Upon acceptance of my entry, I, for myself, my heirs and assigns do hereby release Bethel Rural Community Organization, Inc., Bethel Schools, race sponsors, officials and volunteers from any and all liability arising from illness, injury or death that I may suffer as a result of my participation in either the Half Marathon or 5K Race. I attest that I am physically able and sufficiently trained for the race, which I am entering, and that I am aware that participation could result in physical injury. I grant permission for photos, motion pictures, recording or any other record of the events for any legitimate purpose. I agree to accept as final the decisions of the race officials.
____________________________________________________________________
Entrant Signature or Guardian (if under 18) Date
Please print out this form
Make Checks payable to BRCO, and mail to:
Bethel Rural Community Organization, Inc.
PO Box 1333, Waynesville, NC 28786