Register by mail below, or click 5K registration link at www.chinquapenntrail.org to register online
Name: ___________________________________________ Phone: _____________________________________
Address: ________________________________City:______________________State:_____Zip:____________
Date of Birth: _______________ Gender: [ ] Male [ ] Female Shirt Size: (circle one) S M L XL XXL
Email: _______________________________________________________________Amt enclosed: $_______
Mail form and waiver with check to: FCPWT 230 Roberson Lane Reidsville, NC 27320
Waiver of Liability
I understand that it is important that I be in good physical condition when I engage in this activity, and I understand that it is my responsibility to maintain an activity level that is compatible with my physical condition and skill level. I hereby expressly assume the risk of any physical injury or other loss that I might sustain as the result of participating in this activity. I further understand that there may be a risk of injury traveling to and from the area where the activity will take place. I also expressly waive and covenant not to sue on any claim I might have against the Dan River Basin Association (DRBA), or any officer, board member, or employee of the Dan River Basin Association, or any volunteer, or the estate or representatives of such person(s) for any personal injury or loss I might sustain as the result of engaging in any activity relating to this program whether caused by negligence, breach of contract or otherwise. I understand that photographs may be taken during this event. I grant to DRBA, its representatives and employees the right to take photographs of me and any minors in my company in connection with this activity. I authorize DRBA, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that DRBA may use such photographs of me and any minors in my company, with or without my name, and for any lawful purpose the same in print and/or electronically. I agree that DRBA may use such photographs of me and any minors in my company, with or without my name, and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
Signature of Runner: __________________________________________________________ Date: ______________________
Signature of Guardian: ________________________________________________________ Date: ______________________
(signature required for participants under 18 years of age)
Name: ___________________________________________ Phone: _____________________________________
Address: ________________________________City:______________________State:_____Zip:____________
Date of Birth: _______________ Gender: [ ] Male [ ] Female Shirt Size: (circle one) S M L XL XXL
Email: _______________________________________________________________Amt enclosed: $_______
Mail form and waiver with check to: FCPWT 230 Roberson Lane Reidsville, NC 27320
Waiver of Liability
I understand that it is important that I be in good physical condition when I engage in this activity, and I understand that it is my responsibility to maintain an activity level that is compatible with my physical condition and skill level. I hereby expressly assume the risk of any physical injury or other loss that I might sustain as the result of participating in this activity. I further understand that there may be a risk of injury traveling to and from the area where the activity will take place. I also expressly waive and covenant not to sue on any claim I might have against the Dan River Basin Association (DRBA), or any officer, board member, or employee of the Dan River Basin Association, or any volunteer, or the estate or representatives of such person(s) for any personal injury or loss I might sustain as the result of engaging in any activity relating to this program whether caused by negligence, breach of contract or otherwise. I understand that photographs may be taken during this event. I grant to DRBA, its representatives and employees the right to take photographs of me and any minors in my company in connection with this activity. I authorize DRBA, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that DRBA may use such photographs of me and any minors in my company, with or without my name, and for any lawful purpose the same in print and/or electronically. I agree that DRBA may use such photographs of me and any minors in my company, with or without my name, and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
Signature of Runner: __________________________________________________________ Date: ______________________
Signature of Guardian: ________________________________________________________ Date: ______________________
(signature required for participants under 18 years of age)
