North Carolina Wesleyan College

North Carolina Wesleyan College Skeleton 5K Walk/Run for Bones

To Benefit Bone Cancer Research

Thursday, October 27, 2016

Full Name:

Address:

City: State: Zip:

Email Address: Phone:

Gender: M F Age: Shirt Size: S M L XL

Emergency Contact Name: Phone

Registration fees: $7 Student $13 Non Student PRIOR to 10/20

$8 Student $15 Non Student AFTER 10/20.

I am enclosing a check/money order/cash (circle one) for ______

Please make all checks/money orders to NC Wesleyan College and place 5K in the memo

Send completed forms with registration fees to Skeleton 5K c/o Dr. Danny Henderson, 3400 N. Wesleyan Blvd., Rocky Mount, NC 27804

Waiver of Liability

I know that participating in the Skeleton 5K is a potentially hazardous activity. I assume all risks associated with participating in the 5K run/walk and I do hereby release and discharge N.C. Wesleyan College, their respective directors, and its trustees, officers, employees, agents, independent contractors, and assigns, associates, subsidiaries and partners from any liability whatsoever, including, but not limited to, liability for negligence, and from any claims for damages that allegedly arise out of or relate in any way to any injuries or alleged injuries that I may allegedly suffer in connection with all activities in which I will participate. I hereby acknowledge my mutual receipt of valuable consideration in connection with this release and acknowledge my consent to the terms and conditions of this release. There are absolutely NO refunds, even in the event of a race cancellation. There are absolutely NO transfers of entries to other individuals. NO EXCEPTIONS. Signature: Date

If under 18 Parent/Guardian Signature Date ------Please Fold Here------

______

Bishop Skeleton Run 5K

North Carolina Wesleyan College

c/o Dr. Danny Henderson, Exercise Science

3400 N. Wesleyan Blvd

Rocky Mount, NC 27804

------Please Fold Here and Securely Tape all sides------