Document 407637

Saturday, Dec 6th, 2014 * 8:00am
Valentine, Nebraska
City Gym - 312 E 3rd St.
Route to be announced
This event is open to everyone, all ages & genders
Awards: First Overall Male & First Overall Female
Name: last/first____________________________________________
e-mail address: ____________________________________________
address: _____________________ City: _________________ State_____ Zip ___________
Date of Birth _____________
Age Race Day __________
Race Entry Fee: Pre-registered by Nov 20, 2014: $25*
Nov. 21 thru race day: $40
*20% discount for VH&F running club – gold members
Male ____ Female _____
Payment (circle one) Cash
Check
Credit Card
Make checks payable to valentine health & fitness ctr, llc
Credit Cards (circle one): Visa Mastercard
T-Shirt Size (circle one): S
M
L XL 2XL
(to guarantee a t-shirt you must pre-register)
Drop off your registration at
Valentine Health & Fitness Center, LLC
OR
Mail in to: Valentine Health & Fitness Center, LLC
PO Box 673
Valentine, NE 69201
Credit card number; _____________________________
Exp ________ CVV: ___________
Contact: Brenda Allison at [email protected] or 402-322-1930
Participant Waiver for Race Registration
I know that running [volunteering for] a road race is potentially hazardous activity, which could cause injury or death. I will not enter and participate unless I am medically able
and properly trained, and by my signature, I certify that I am medically able to perform this event, and am in good health, and I am properly trained. I agree to abide by any
decision of a race official relative to any aspect of my participation in this event, including the right of any official to deny or suspend my participation for any reason whatsoever. I
attest that I have read the rules/etiquette of the race and agree to abide by them. I assume all risks associated with running in this event, including but not limited to: falls, contact
with other participants, the effects of the weather, including high heat and/or humidity, traffic and the conditions of the road, all such risks being known and appreciated by me. I
understand that bicycles, skateboards, roller skates or roller blades, animals, strollers, and personal music players are not allowed in the race and I will abide by all race rules.
Having read this waiver and knowing these facts and inconsideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the Santa
Shuffle, the city of Valentine, Valentine Health & Fitness Center, LLC, all event sponsors, their representatives and successors 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 my photographs, motion pictures, recordings or any other record of this event for any legitimate purpose.
Signature:_______________________________
Parent’s Signature if under 18 years: _________________________________
Date: ____________
Date: ____________
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