Saturday, September 20, 2003 • 8:00 AM Bluemont, Virginia (in Loudoun County)

'03 Race Info > '03 Entry Form Course Map Past Results

                    2003 Bluemont Fair 10K Entry Form                     


Name: ____________________________________________________________________

Address: _________________________________________________________________

City: ______________________________   State: _______   Zip: _____________

Phone number: _________________________    Date of birth: ________________

Sex: ________   Age: _________    Shirt size (circle one):    M    L    XL


Waiver:  In consideration of my application being accepted, I hereby, for 
myself, my heirs, and executors waive, release and forever discharge any  
and all rights and claims for damages, demands, or actions which I may    
have or may hereafter accrue to me against the Bluemont Fair 10K, Race    
Committee, BCA, Bluemont Methodist Church, all sponsors and volunteers of 
the Bluemont Fair 10K for any and all injuries suffered by me in any      
manner, in said event.                                                    


SIGNATURE: _________________________________   DATE: _____________________

Parent's or guardian's signature if entrant under 18:                     


SIGNATURE: _________________________________   DATE: _____________________


Please mail completed form and check ($15 if received by 9/17) to:        

   Bluemont Fair 10K Race                                                 
   Box 217                                                                
   Bluemont, VA 20135                                                     

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