Third Annual Chesty Puller
Memorial 10K Race Registration Form
Make checks payable to: “Town of
Mail to: Chesty
First Name __________________ MI ______ Last Name ______________________
Phone # ____________________ E-mail __________________________________________________
Age on Race Day ______ Date of Birth ____/____/____ Gender ____M ____F
Runners/Walkers Agreement Waiver, Release & Acknowledgement. All runners/walkers are required to sign this waiver. I know that running/walking a road race is a potentially hazardous activity. I should not enter unless I am medically able and properly trained. I agree to abide by any decisions of a race official relative to my ability to safely complete the run/walk. I assume the risk associated with running/walking this event, including, but not limited to falls, contact with other participants, the effects of weather, including, high heat and/or humidity, traffic and the conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the Town of West Point, Peninsula Track Club, all sponsors, their representatives and successors from all claims or liabilities of any kid arising out of my participation in this event. I grant permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose. The Peninsula Track Club and Road Runners of America are excluded from liability.
Signature and/or signature of Parent or Guardian if less than 18 years of age Date
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Finish line results and race supported by
the
No PTC Race Passes Accepted
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WALKING IS PERMITTED
REFRESHMENTS WILL BE SERVED AFTER THE RACE
RANDOM DRAWINGS FOR DOOR PRIZES!