The USATF 5K Race Walk Championship
and the USA Junior Championship
Entry Form
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First Name:
Last Name
Sex:
Male
Female
Age on 10/09/10 race day:
Birthdate (MM-DD-YY):
USATF Membership Number:
Street Address:
City:
State:
Zip:
Telephone:
Email Address:
T-shirt Size:
S
M
L
XL
XXL
Please print out this form, sign it, and mail with check to:
Bank of Tennessee
Attention: Renee Kleineick
P.O. Box 4980
Johnson City, TN 37602
Race Walk Entry Fee:
$25.00/ person
Race Walk Clinic Fee:
$30.00/ person
Amount Enclosed:
Make check payable to:
Kingsport American Way Race Walk
I hereby waive all claims for myself, my heirs, and executors against the Kingsport USATF 5K Race Walk Championship and the USA Junior Championship, its sponsors, agents, and employees for any claims and liabilities which may result from my participation. I assume all risks associated with participating in the USATF 5K Race Walk Championship and the USA Junior Championship, but not limited to, falls, contact with other participants, the effects of the weather and conditions of the course, all such risks being known and understood by me. I further state that I am physically able to compete in my registered event.
Signature and Date:
