1040 Tax Fun Run/Walk 5K Registration

1040 Tax Fun Run/Walk 5K
Saturday, April 16, 2016 at 10:40 a.m.
Eagle Mountain Elementary School, Batesville, AR

Entry Fee is $10.40, (pre-registration, mailed in by April 8, 2011). Day of race registration will be from 9:00 a.m. to 10:15 a.m. on day of race at Eagle Mountain Elementary School, cost will be $15.00.

Last Name___________________________First Name___________________________

Date of Birth______________________Sex M_____F______ Age on Race day_______

Address_______________________________________________________________

City______________________________State________________Zip______________

T-Shirt Size Circle One: Youth Med Youth Large Adult S Adult M
Adult L Adult XL Adult XXL

Circle One: Runner 5k Walker 5k

Big Brother or Big Sister Rate (Kids Only) is $5.20, Please check here:_______

Make checks payable to and mail to: White River Roadrunners, 169 W. Ross St. Batesville, AR 72501

RACE RELEASE (Must be signed by participant/parent or guardian)

I understand that my consent to these provisions is given in consideration of the acceptance of this registration and for being permitted to participate in this event. I am a voluntary participant in this event, and in good physical condition. I know that this is a potentially hazardous activity and I hereby assume full responsibility for any injury or accident which may occur during my participation in this event or while on the premises of this event. In consideration of acceptance of this entry, I waive and release any and all claims for myself and my heirs against the race organizers and any and all sponsors of this race from any liability or any loss, damage, or injury which I may incur as a result of my participation in this race. I further state that I have trained and I am in proper physical condition to participate in this race. This entry is not valid unless signed by entrant. If entrant is under 18 years of age, parent or guardian must sign entry form. Entry form not valid without signature and will be returned. Must have one form per person with signature. Photocopies are acceptable.

Signature__________________________________________Date__________________

Parent/Guardian Signature_________________________________Date______________

IPICO CHIP Instructions
1. All timed participants must pick up a timing chip race morning.
2. Timing chips must be affixed to your shoelace with a zip tie provided race morning.
3. Please do not swap timing chips with family or friends.
4. Only participants wearing a timing chip will have a recorded finishing time.
5. Return your timing chip to a volunteer after you finish.
6. Please do not exit the finish chute with your race-day timing chip.
7. Participants will be charged $30 for timing chips not returned after the race.