Saturday, May 12, 2012

Last Name___________________________First Name___________________________

Date of Birth______________________Sex M_____F______ Age on Race day_______

Address_______________________________________________________________

City______________________________State________________Zip______________

Phone Number:____________________________________

T-Shirt Size (Circle One): Youth Medium - Youth Large - Adult Small - Adult Medium - Adult Large - Adult X-Large - Adult XX-Large

Please Circle One: 5kRUNNER - 5kWALKER - Kid's Run

ENTRY FEE:

Pre-Registration Fee; WRHS Employee: $15.00, Payroll Deduct WRHS Employees: Employee ID No.___________(will be deducted in 1 pay period).

Kid's Run: $10.00         General Public: $20.00

Pre-Registration Deadline is May 7, 2012 Entry Fee after deadline will be $25.00 for everyone. Except Kids run will stay at $10.00.

Day of Race registration (6:30 - 7:30 a.m.): Adults: $25.00 **Race Starts at 8:00am.**

Make checks payable to: White River Medical Center and mail to: WRMC 5K/Cardiac Rehab, 1710 Harrison 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.

Signature__________________________________________Date__________________

Parent/Guardian Signature_________________________________Date______________

Entry form not valid without signature and will be returned. Parents must sign for children under 18. Must have one form per person with signature. Photocopies are acceptable.

Instructions

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.