join us in supporting middle school athletics!
JOIN US IN SUPPORTING MIDDLE SCHOOL ATHLETICS! COURSE: The certified 5K loop will begin and end at Blakeney Shopping Center (at the corner of Ardrey Kell and Rea Road) RACE INFO: www.bigsouth5k.com, or call us at 704-341-7990 th
FINISH LINE PARTY: After the race, join us for food, beverages, prizes, vendors, and the 10 Annual Blakeney Boo! Bash AWARDS: TOP 3 Overall (M/F), TOP 3 Masters (M/F), TOP 3 Age Group (15 divisions M/F), TOP 3 Corporate Team Division Awards, and TOP 3 Community Team Awards PURPOSE: A fundraiser for middle school athletic programs in Mecklenburg, Union, Lancaster, and Fort Mill.
CUT ALONG THIS LINE
BIG SOUTH 5K INDIVIDUAL ROAD RACE ENTRY FORM (PLEASE PRINT CLEARLY!)
NAME: __________________________________________________ TEAM NAME (if necessary): _________________________________ PHONE: _________________________________________________ ADDRESS: _______________________________________________ CITY: _____________________ STATE: ______ ZIP: _____________
Number
Rates
Total
$20 through July 31st
$
$25 starting August 1st
$
$30 Starting October 12th
$
$20 “Phantom Runner”*
$
Grand Total Due
$
SHIRT SIZE (YM-XXL): ________ DATE OF BIRTH: _______________ EMAIL: _________________________________________________
*A phantom runner does not participate in the race, but does receive a t-shirt.
MIDDLE SCHOOL BENEFICIARY (if desired): ____________________ BIG SOUTH PARTICIPANT WAIVER AND RELEASE: WAIVER AND RELEASE MUST BE READ AND SIGNED WITH ENTRY. IN CONSIDERATION OF ACCEPTANCE OF MY APPLICATION TO PARTICIPATE IN THE BIG SOUTH 5K ROAD RACE, I WAIVE AND RELEASE ALL CLAIMS FOR MYSELF, MY HEIRS AND ASSIGNS AGAINST THE BIG SOUTH CONFERENCE, INC., THE TIMING COMPANY, AND ALL SPONSORS, ALL OFFICERS, DIRECTORS, AND MEMBERS OF SAID ORGANIZATIONS, AND THEIR RESPECTIVE EMPLOYEES, AGENTS, VOLUNTEERS AND ANY OTHER INDIVIDUALS WHO ARE IN ANY WAY ASSOCIATED WITH THIS EVENT, FOR ANY DAMAGES, ILLNESS OR INJURY OF ANY KIND WHATSOEVER WHICH MAY RESULT FROM MY PARTICIPATION IN THE BIG SOUTH 5K ROAD RACE THIS WAIVER AND RELEASE EXTENDS TO ALL CLAIMS OF EVERY KIND WHATSOEVER, FORESEEN, AND UNFORESEEN, KNOWN AND UNKNOWN, TO THE FULLEST EXTENT PERMITTED BY LAW. BY ENTERING THIS EVENT, I AGREE TO ACCEPT THE RISKS AND TAKE FULL RESPONSIBILITY FOR MY OWN WELL-BEING. I AGREE THAT EVENT OFFICIALS ARE AUTHORIZED TO OBTAIN EMERGENCY TREATMENT FOR ME IN THE EVENT I AM INCAPACITATED. I GIVE PERMISSION FOR THE UNCOMPENSATED USE OF MY NAME AND PICTURE IN AN ACCOUNT, PUBLICATION, BROADCAST, OR TELECAST OF OR REGARDING THIS EVENT FOR ANY LEGITIMATE PURPOSE. I ALSO ACKNOWLEDGE THAT THE OFFICIAL RACE DIRECTOR RESERVES THE RIGHT TO POSTPONE OR CANCEL THE RACE, OR TO CHANGE THE DAY AND/OR TIME, WITHOUT REFUND OF ENTRY FEES. I CERTIFY THAT I HAVE READ THE FOREGOING AND ACCEPT ITS TERMS. IF THE PARTICIPANT IS UNDER 18 YEARS OF AGE, A PARENT OF LEGAL GUARDIAN MUST SIGN THE WAIVER AND AGREE TO ITS TERMS.
SIGN:
DATE: **CUT ALONG THE DOTTED LINE ABOVE AND RETURN THE RACE ENTRY FORM INCLUDING THE SIGNED WAIVER WITH PAYMENT TO: BIG SOUTH 5K ROAD RACE, C/O FLETCHER JONES, 7233 PINEVILLE-MATTHEWS ROAD, SUITE 100 CHARLOTTE, NC 28226 OR COMPLETE AN ENTRY FORM ONLINE AT WWW.BIGSOUTH5K.COM! **MAKE CHECKS PAYABLE TO BIG SOUTH CONFERENCE**
FINISH LINE PARTY: After the race, join us for food, beverages, prizes, vendors, and the 10 Annual Blakeney Boo! Bash AWARDS: TOP 3 Overall (M/F), TOP 3 Masters (M/F), TOP 3 Age Group (15 divisions M/F), TOP 3 Corporate Team Division Awards, and TOP 3 Community Team Awards PURPOSE: A fundraiser for middle school athletic programs in Mecklenburg, Union, Lancaster, and Fort Mill.
CUT ALONG THIS LINE
BIG SOUTH 5K INDIVIDUAL ROAD RACE ENTRY FORM (PLEASE PRINT CLEARLY!)
NAME: __________________________________________________ TEAM NAME (if necessary): _________________________________ PHONE: _________________________________________________ ADDRESS: _______________________________________________ CITY: _____________________ STATE: ______ ZIP: _____________
Number
Rates
Total
$20 through July 31st
$
$25 starting August 1st
$
$30 Starting October 12th
$
$20 “Phantom Runner”*
$
Grand Total Due
$
SHIRT SIZE (YM-XXL): ________ DATE OF BIRTH: _______________ EMAIL: _________________________________________________
*A phantom runner does not participate in the race, but does receive a t-shirt.
MIDDLE SCHOOL BENEFICIARY (if desired): ____________________ BIG SOUTH PARTICIPANT WAIVER AND RELEASE: WAIVER AND RELEASE MUST BE READ AND SIGNED WITH ENTRY. IN CONSIDERATION OF ACCEPTANCE OF MY APPLICATION TO PARTICIPATE IN THE BIG SOUTH 5K ROAD RACE, I WAIVE AND RELEASE ALL CLAIMS FOR MYSELF, MY HEIRS AND ASSIGNS AGAINST THE BIG SOUTH CONFERENCE, INC., THE TIMING COMPANY, AND ALL SPONSORS, ALL OFFICERS, DIRECTORS, AND MEMBERS OF SAID ORGANIZATIONS, AND THEIR RESPECTIVE EMPLOYEES, AGENTS, VOLUNTEERS AND ANY OTHER INDIVIDUALS WHO ARE IN ANY WAY ASSOCIATED WITH THIS EVENT, FOR ANY DAMAGES, ILLNESS OR INJURY OF ANY KIND WHATSOEVER WHICH MAY RESULT FROM MY PARTICIPATION IN THE BIG SOUTH 5K ROAD RACE THIS WAIVER AND RELEASE EXTENDS TO ALL CLAIMS OF EVERY KIND WHATSOEVER, FORESEEN, AND UNFORESEEN, KNOWN AND UNKNOWN, TO THE FULLEST EXTENT PERMITTED BY LAW. BY ENTERING THIS EVENT, I AGREE TO ACCEPT THE RISKS AND TAKE FULL RESPONSIBILITY FOR MY OWN WELL-BEING. I AGREE THAT EVENT OFFICIALS ARE AUTHORIZED TO OBTAIN EMERGENCY TREATMENT FOR ME IN THE EVENT I AM INCAPACITATED. I GIVE PERMISSION FOR THE UNCOMPENSATED USE OF MY NAME AND PICTURE IN AN ACCOUNT, PUBLICATION, BROADCAST, OR TELECAST OF OR REGARDING THIS EVENT FOR ANY LEGITIMATE PURPOSE. I ALSO ACKNOWLEDGE THAT THE OFFICIAL RACE DIRECTOR RESERVES THE RIGHT TO POSTPONE OR CANCEL THE RACE, OR TO CHANGE THE DAY AND/OR TIME, WITHOUT REFUND OF ENTRY FEES. I CERTIFY THAT I HAVE READ THE FOREGOING AND ACCEPT ITS TERMS. IF THE PARTICIPANT IS UNDER 18 YEARS OF AGE, A PARENT OF LEGAL GUARDIAN MUST SIGN THE WAIVER AND AGREE TO ITS TERMS.
SIGN:
DATE: **CUT ALONG THE DOTTED LINE ABOVE AND RETURN THE RACE ENTRY FORM INCLUDING THE SIGNED WAIVER WITH PAYMENT TO: BIG SOUTH 5K ROAD RACE, C/O FLETCHER JONES, 7233 PINEVILLE-MATTHEWS ROAD, SUITE 100 CHARLOTTE, NC 28226 OR COMPLETE AN ENTRY FORM ONLINE AT WWW.BIGSOUTH5K.COM! **MAKE CHECKS PAYABLE TO BIG SOUTH CONFERENCE**
