2002 Loudoun Street Mile Entry Form
Name: ______________________________________ Sex: _______ Age: _______
Address: _________________________________________________________________
City: _______________________________ State: _______ ZIP: ____________
Phone number: _________________________ Tank top size: S M L XL
Youth shirt: M L
Mile heat? Walkers Team Open women Open men Special Olympics
(circle one)
Kids half-mile Kids quarter-mile Kids 100 yd. dash
WAIVER: In consideration of your accepting this entry, I, the undersigned, intending to be legally bound, hereby for myself, my heirs, executors, and administrators, waive and release any and all rights and claims for damages I may have against any of the following: City of Winchester, BB&T Bank of Winchester, Downtown Development Board, Richard Kerby, Shenandoah Valley Runners, Valley Health System, the Shelter for Abused Women, and any and all additional contributors and sponsors and assigns for any injuries suffered by me in the scheduled July 20th, 2002 event. I attest and verify that I am physically fit and have effectively trained to complete this race.
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SIGNATURE: _________________________________ DATE: _____________________
Parent's or guardian's signature if entrant is under 18:
SIGNATURE: _________________________________ DATE: _____________________
Please make checks payable to "SVR - Loudoun Street Mile", and mail to:
Loudoun Street Mile
3916 Old Charlestown Road
Berryville, VA 22611
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