Race Waiver

I know that running a good race is a potentially hazardous activity and I should not enter unless I am medically stable and properly trained. I assume all risks associated with running or walking in this event including, but not limited to, falls, contact with other participants, the effects of weather and the conditions of the road, all of such risks being known and appreciated by me. Having read this waiver and knowing the facts and in consideration of your accepting my entry, I, for myself, and anyone else acting on my benefit waive and release and indemnify the organizers of the EmpoweRun, Davie Domestic Violence Services & Rape Crisis Center, County of Davie, plus all sponsors, their representatives and assignors 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 also give my permission for the free use of my name and picture in any written account, broadcast or telecast of this event for any legitimate purpose. By signing the front side of this form, I accept this waiver

Our Mission
The mission of Davie Domestic Violence Services & Rape Crisis Center is to end domestic violence and sexual assault in our community through empowerment, advocacy, education, awareness, and action for a social change.

Davie Domestic Violence Services & Rape Crisis Center and

Presents

Visit us on Facebook!

facebook.com/DavieDomesticViolenceServices

Running for a Violence-Free Community

Contact Us
Davie Domestic Violence Services & Rape Crisis Center 123 South Main Street Mocksville, NC 27028 Phone: (336) 751-3450 Fax: (336) 751-3451 lorri.hayes@co.davie.nc.us

Saturday
March 29, 2014
Bermuda Run Country Club

WHO
You and Davie Domestic Violence Services & Rape Crisis Center

Official Registration
One per entrant, copies accepted. Name:

WHAT
EmpoweRun 5K/Walk (3.1 miles)

Fees
Until January 31 Febuary 1st -March 15 March 16 March 28th Race Day
th

First

Last

$20 $25 $30 $35

Address:
Street

WHEN
Saturday, March 29 Registration 7:30-8:30 9:00 AM Race Starts

City

State

Zip

Phone: Email: Gender:

Male Female

WHERE
Bermuda Run Country Club 324 Bermuda Run Drive Bermuda Run, NC 27006

Register Online
www.ultimateracemanagement.com

Adult T-Shirt Size (please circle one):

For the first 200 participants

WHY
To take a step to end domestic violence and sexual assault, and to encourage friends, family, and coworkers to come and enjoy a day of family friendly activities, while supporting victims of domestic violence and sexual assault.

For more info contact Bill Gibbs (336) 403-7557 runthelastmile@bellsouth.net Online Closes 3/26/14 Mail-Ins by 3/23/14

XL

XXL

By signing, I accept the Race Waiver as printed on the back of this form.

Signature (parent or guardian if under 18)

Packet Pick-Up will be located at DDVS & RCC

Registration Information

Childrens Activities
Provided & Supervised by Davie County School Counselors -Indoors For K-5 age groups
(Drop off at Registration Time 7:30)

Select one:
Individual I am on Team:

Select One:
Runner Walker

Team Name Please make checks payable to DDVS/RCC