5K Application

Please complete and sign this form, include your entry fee and mail to
Kiwanis Club of North Buncombe, P.O. Box 2207, Weaverville, NC 28787

Firecracker 5K ENTRY FORM

Make check payable to:
Kiwanis Club of North Buncombe
P.O. Box 2207
Weaverville, NC 28787

____ Entry Fee (Until 6/20/11) $20.00

____ Entry Fee (After 6/20/11) $25.00

Last Name_________________________________ First Name______________________________________

Mailing Address____________________________City_______________________State___________ZIP________

E-mail _____________________________________________________________

Age on Date of Race_________________ Female_____________ Male__________________

Daytime Phone # ____________________

T-Shirt Size	____ S	____ M	____ L	____ XL	____ XXL
_____ Keep the Shirt (Donate proceeds to scholarships)

Waiver: I know that running and participating in this event is potentially hazardous. I should not enter and run in this event unless I am medically able and properly trained. I agree to abide by any decision of an official relative to my ability to safely complete this event. I assume all risk associated with running and training for this event including, but not limited to falls, contact with other participants, the effects of the weather, including the conditions of the roads and traffic on the course, all such risks being known and appreciated to me. Having read this waiver and knowing the facts, and in consideration of your acceptance of my entry, I, for myself am entitled to act in my behalf, waive and release all sponsors, their representatives and successors and any individual or group associated with this event 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 grant permission to all of the foregoing to use any photographs, motion pictures, recordings, verbal or written statements, or any other record of this event for any legitimate purpose.

Signature_________________________________________________________Date________________________

(If under 18 parent or guardian)
Race will be held rain or shine. Race Director reserves the right to disqualify any participants.

Please