Last Name______________________ First Name ___________________ Sex ___
Mailing Address_________________________________________________________
City____________________________________ State ____ Zip ________________
Emal _________________________ Phone ________________ Birth date _______
Event Circle one 5K ($10/$20 race day) Age on 02/09/03 ______
Youth Mile ($5/10 Race day)
Fun Run (Free)
Team Catagory Circle one (Both runners must fill out a form)
Mother/Daughter Mother/Son Father/Son
Father/Daughter Brother/Sister Sister/Sister
Brother/Brother Open/Coed
Partner's Name _____________________
T-Shirt Size (5K, Youth mile, and Sweetheart catagories only)
Circle one Youth: Medium Large
Adult: Small Medium Large Xtra-Large
Fee Enclosed: $_________
Waiver: In consideration of this entry, I, my heirs, administrators, and
assigns, hereby release and will hold harmless the race organizers, officials,
sponsors, and all agents, employees, officers, directors and volunteers
working for those entities, from all claims and liabilities arising from my
participation in the Valentine Run. I realize that this is a strenuous event
that requires proper physical conditioning. I hereby certify that I am in
such physical condition and good health. I further realize that risks include,
but are not limited to, falls, contacts with other participants, the effects of
the weather, including extreme cold, and conditions of the road. I also give
my permission for the free use of my name and picture in any written account,
broadcast, or telecast of this event.
Signature of Entrant _______________________________ Date ____________
Signature of Parent/Guardian (if participant is under 18)
_______________________________________________ Date ___________
Make Checks Payable to: Black Mountain Recreation and Parks
101 Carver Avenue
Black Mountain, NC 28711