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tviicic. ▼▼ <u i ciiiuii visiior s center, rwcun aireei, warrenion, Virginia . ■■. When: Sunday September 28, 1997 • Time: Race begins at 8:00 AM. Registration on day of event from 7:30 - 7:45AM Cost: $15.00 for those who pre-register by September 24, $20.00 after September 24 and day of run. Fee includes an “Alive And Kicking” T-Shirt for the first 150 registered. To register, complete this form and return with application fee (payable to Fauquier Hospital) to Physician Referral Service, Fauquier Hospital, 500 Hospital Drive, Warrenton, VA 20186.
La* Name-First Name._Middle Initial_ Birth Date ___
City.___ Suite ___ Zip_ Phone Numbers Work Home
---- -—Please check the appropriate box for your age category at the time of the race. □ Male • □ Female
□ 14 & under 015-18 019-25 0 26-30 0 31-35 0 36-40 0 41-50 0 51-60 Q61&over
All entries must include the signed waiver below I know that running a road race is a potentially hazardous activity. I should not enter and run unless I am medically able and properly trained. I assume all risks associated with running in this event, including, but not limited to: falls, contact with other participants, the effects of the weather, including high heat and/or humidity, traffic and conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of the acceptance of my entry, I. for myself and anyone entitled to act on my behalf, wait and release Fauquier Hospital and the Town of Warrenton and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event, though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver. I grant permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose.
Signature (parent's signature if participant is under 18 years of age)
Date
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