2011 REGISTRATION FORM
(please print this page and fill out or Click Here for text version)
Pre-Registration: $17 Race Day Registration: $20
MAKE CHECKS PAYABLE TO: Farm Bureau Scholarship Fund
**All registrations are non-refundable. Proceeds benefit the R. Flake Shaw Scholarship Program fund of the NC Farm Bureau.**
Packet Pick-up will be from 8:15-8:45 am on the day of the race.
For more information contact: Please complete and return to:
Janet Moretz Farm Bureau Scholarship Fund
828-264-9480 c/o Janet Moretz
moretzjs@appstate.edu 215 Len Moretz Road
Boone, NC 28607
Farm Bureau Scholarship Run – September 17, 2011
Name: _______________________________________ Male _____ Female _____
Address: ________________________________________________________________________
City/State: ____________________________________ Zip: ___________________
Phone: __________________ Age on race day: _____ Date of Birth: __________
Email address: __________________________________________________________
Shirt size: Child: _______(SML)
Adult: _______Small _______ Medium ______Large ______XL ______XXL
(shirt size not guaranteed on day of race)
Participant Waiver:
In consideration of my or my child's participation in the aforementioned running event, I hereby discharge and release the NC Farm Bureau, the town of Todd, any and all employees and agents thereof of all claims of any kind whatsoever arising out of the actions of the above said participants or agents, to the extent allowed by law. I have informed the race staff of any physical conditions that may hinder my or my child's participation in the 2011 Railroad Grade Run.
________________________________________ ________________________________________
Printed Name (participant, or parent/guardian of minor) Signed Name (participant, or parent/guardian of minor)