Paper Registration
Last Name:_______________________________First Name:___________________________
Address:________________________City:__________________State: _____Zip:___________
Phone:____________________________Email:_______________________________________
Emergency Contact:___________________________________Phone:____________________
In order to guarantee a t-shirt in your preferred size, registration must be RECEIVED by March 2. After that t-shirts will be distributed on a first come, first serve basis.
T-shirt (circle one) No T-shirt Women’s S M L XL Men’s S M L XL
Sex: (Circle One) M F Age on March 31, 2012: ______ Course: (circle one) 5K 10K
Waiver: In consideration of the acceptance of this entry, I for myself, my heirs, and assigns, hereby release the sponsors, race workers, and officials of the Greenway Challenge from any and all liability arising from illness and damages I may suffer as a result of participation in such an event. I attest that I am physically fit and have sufficiently trained for this event and am aware that participation in this event could, in some circumstance, result in severe physical injury or soreness. I also give my permission for free use of my name and picture in any broadcast/telecast or written account of this event. I understand that the entry fee I determine I pay is non-refundable. Should road race officials determine that the completion of this event would be injurious to my health, I consent to be removed from the course and treated by a physician in attendance or of their direction.
Signature _________________________________________________ Date: ________________
Parent/guardian signature if participant under 18 ________________________________________
If mailing in your entry fee, it must be postmarked by March 23. Race entry fee: $24.00 without t-shirt. $35.00 with a t-shirt. If you are a ATC Grand Prix member or you ran in last year’s race, you may reduce your fee by $5.00. Send check payable to Black Mountain Greenway Challenge along with this completed registration form to:
Black Mountain Greenway Challenge ℅ Jon McNair 375 Lake Eden Rd. Black Mountain, NC 28711
