Registration Form - Ryan’s Reindeer 5K Run/Walk
Saturday December 17, 2016
Name ____________________________________ Race Location: Medical Arts Bldg Address___________________________________ Downtown Fayetteville 101 Robeson St. City ___________________State_____ Zip_______ 12/16/2016 5-8 pm Packet pick up Contact Phone # _____________________________ and registration, Breezewood Healthcare
E-Mail ____________________________________ 200 Forsythe Street Fayetteville, NC 28303
Age on Race Day _______ Date of Birth __________ 12/17/16 7:00am packet pick up
Male ________ Female _________ and same day registration at
Adult T-Shirt size (please circle): S, M, L, XL, 2XL($3 extra) race location. 8:30am race start.
Youth T-Shirt size (please circle): YS, YM, YL .
To guarantee a T-shirt registration must be received by December 1, 2016.
$25.00 Individual Runner/Walker, After December 1: $30.00
Under 13 runner/walker $15.00, after December 1: $20.00
Family Entry: $75.00, After December 1: $90.00 (includes 4 T-shirts) 2 additional family members may register for $20.00 each.
Family registrants will not be eligible for individual prizes but will be eligible for the family prize. Times of all family members will be added together to get the family time. A family consists of a minimum of 3 and a maximum of 6 runners who are of the same family. Children in strollers are not counted. Please complete a separate registration form for each participating family member.
Individual Runner/walker $________ Under 13 Runner/walker $________ Cash or Checks Payable to: Family Entry $________ RPK Memorial Foundation Extra Family Members (max 2) $20 each $________ PO Box 58034
Add $3 for each 2XL t-shirt requested $________ Fayetteville, NC 28305
Extra T-shirts (YS through Adult XL $12 each : 2XL $15 each)
S___ M___ L ___ XL___ 2XL_____YS ____ YM____ YL_____
Total for Extra T- shirts $_________
Optional Tax Deductible donation $ _________ Group Trophy to group with most members
Total Amount enclosed $ _________ registered by December 16, 2016.
Group Name ___________________________
Please make sure to sign waiver and release form.
Waiver—Must be signed to participate
I understand that participating in this event is potentially hazardous, and that I should not enter and participate unless I am medically able and properly trained. In consideration of the acceptance of this entry, I assume full and complete responsibility for any injury or accident, which may occur while I am traveling to or from the event, during the event, or while I am on the premises of the event. I also am aware of and assume all risks associated with participating in this event, including but not limited to falls, contact with other participants, effect of weather, traffic and conditions of the road. I, for myself and my heirs and executors, hereby waive, release and forever discharge the event organizers, sponsors, promoters, Ryan Kishbaugh Memorial Foundation, City of Fayetteville, Cumberland County Hospital System, High Smith Rainey Medical Arts Building Association, EHM Finish Lines/Atlantic Coast Timing Services, Breezewood Healthcare, and each of their agents, representatives, successors and assigns, and all other persons associated with this event, for all liabilities, claims, actions, or damages that I may have against them arising out of or in any way connected with my participation in this event. I understand that this waiver includes any claims, whether caused by negligence, the action or inaction of any of the above parties, or otherwise. I understand that bicycles, skateboards, roller skates or blades are not allowed in the race, and I will abide by these guidelines. I understand that the entry fee is non-refundable and non-transferable. I hereby grant full permission to any and all of the above parties to use any photographs, videotapes, recordings or any other record of my participation in this event for any legitimate purpose.
_______________________________________ ____________________________________________ Signature Date Signature of Parent or Guardian (if under 18) Date