Name: _____________________________________ Sex: _______ Age: _______
Street address: _________________________________________________________
City: _____________________________ State: _______ Zip: _____________
Phone number: _________________________ Circle one: 5K Kids Run
Shirt size: Adult S Adult M Adult L Kids S Kids M
WAIVER: In consideration of your acceptance of my entry, I do hereby
release the sponsors of the Liberty 5K jointly and separately, from any
and all liability for illness, injury, and damages I may suffer as a
result of my participation in this event. I understand the sponsor may
use my name in the publicity and promotion of this event.
SIGNATURE: _________________________________ DATE: ____________________
Parent's or guardian's signature if entrant under 18:
SIGNATURE: _________________________________ DATE: ____________________
Please make checks payable to "Shenandoah Valley Runners", and mail to:
Liberty 5K
c/o Rosie Schiavone
1040 Breckinridge Lane back to main page
Winchester, VA 22601
