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SLAY THE DRAGON 5K WALK/RUN ENTRY FORM 9/26/2009, 9:00 AM Carter Park, Ashland, VA 23005Name: ________________________________________________ Address: _______________________________________________ City/state/zip: ____________________ email address: ___________________ Telephone
#: _______________
Age on race day: ____________ Sex:
Male or Female (circle one)
Emergency contact: ______________________ Walking
or running: ______________ T-shirt
size: S M L
XL (adult sizes)
S M L XL (youth
sizes) Sign up by August 1, 2009 Entry Fee: $15.00Entry fee: $20.00 after August 1, 2009 (If paying by check, please list the check #_____) PACKET
PICKUP THURSDAY 9/24/09 4:00-7:00 AT CARTER PARK **Make checks payable to: NLMSF and put “Slay the Dragon 5K”
on the memo linePlease mail entry form and payment to:
Slay the Dragon 5K P.O. Box 1203 Ashland, VA 23005 Participant Waiver:I know that participating in a 5K event is a potentially hazardous activity. I should
not enter and participate unless I am medically able and properly trained. I agree to abide by any decision
of a race official relative to my ability to safely complete the course. I assume all risks associated
with this event including, but not limited to: falls, contact with other participants, the effects of the weather, including
high heat and humidity, traffic, wet and/or uneven surfaces and the conditions of the road, all such risks being known and
appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting
my entry, I, for myself and anyone else entitled to act on my behalf, waive and release “Slay the Dragon 5K’ and
its officers, the National LeioMyoSarcoma Foundation (NLMSF) and its agents, and all event sponsors and their representatives
and employees from all claims or liabilities of any kind arising out of my participation in this event even though that liability
may arise out of negligence or carelessness on the part of the persons named in this waiver. I grant permission
to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate
purpose. Signature: _______________________________________________
Date: __________ All Participants Sign (Parent or
guardian if under the age of 18) NLMSF.org Slaythedragon5K.com
email:info@slaythedragon5k.com
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