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| 2023 Entry Form |
Name: __________________________________________________________________
Address: _______________________________________________________________
City: _____________________________ State: _______ Zip: ____________
Age on 10/28: _______ Sex: _______ Date of birth: __________________
Phone number: __________________________________________________________
E-mail address: ________________________________________________________
Emergency contact name: ________________________________________________
Emergency contact phone: _______________________________________________
Running club(s) to which you belong: ___________________________________
Okay for G-G to e-mail you future updates? (see below) ___ yes ___ no
Entry fee: ____ SVR member WITH beanie ____ SVR member, NO beanie
(check one) ($28 early/$38 race day) ($22 early/$32 race day)
____ Non-member WITH beanie ____ Non-member, NO beanie
($30 early/$40 race day) ($24 early/$34 race day)
Optional additional donation to the event: $_____________
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| WAIVER: In consideration of your accepting this entry, I, the undersigned, intending to be legally bound, hereby for myself, my heirs, executors, and administrators, waive and release any and all rights and claims for damages I may have against any of the following: the Shenandoah Valley Runners, the Road Runners Club of America, race director Karsten Brown, the Browntown Community Center Association, the owners of the property on which the race is being staged, and all additional contributors, sponsors, and assigns for any injuries suffered by me and/or any damages sustained to my personal property during the scheduled October 28th, 2023 event. I attest and verify that I am physically fit and have effectively trained to complete this race. I assume all risks associated with running in this event, including but not limited to: falls, contact with other participants, the effects of weather, traffic, course conditions, and encounters with wild or domestic animals. I waive any and all claims which I might have based on any of those and other risks typically found in running a road race. I acknowledge that all such risks are known and understood by me. I understand that on-site medical assistance will not be available at this event, and I freely accept the additional risk this presents in the event of an illness, injury, or medical emergency arising during the event. Should such an illness, injury, or medical emergency arise, I hereby authorize and give my consent to the event director to secure from any accredited hospital, clinic, and/ or physician any treatment deemed necessary for my immediate care. I agree that I will be fully responsible for payment of any and all medical services and treatment rendered to me, including but not limited to medical transport, medications, treatment, and hospitalization. I understand the event's rules and restrictions, including its strict prohibitions on: Use of headphones/earbuds/personal listening devices; running/walking with dogs or other pets; use of baby joggers/strollers (unless medically necessary); being "paced" or accompanied on the course by any individuals who are not registered for the event; littering (with the exception of discarding cups within 500 feet of an official water stop); and abusive, offensive, or unsportsmanlike behavior directed at race officials, volunteers, or other participants. I agree to abide by the decision of any race official relative to my participation, and I understand that violation of any of these rules will result in my disqualification and possible ban from future events. I attest that the registration information I have provided is correct and accurate, and I understand that my name, age, gender, hometown, and finish time will appear in publicly-available race results. Further, I grant permission to use my name, voice, and images of myself in any photographs, motion pictures, publications, or any other print, videographic, or electronic recording of this event for legitimate purposes, including but not limited to news coverage, race promotion, and advertising. I accept that my entry fees, and any additional donations/contributions I may make to this event, are non-refundable. I understand and accept that the organizers may postpone or cancel the event due to severe weather, natural disaster, emergency, or other reasons to protect the safety of participants and volunteers, and I am not entitled to a refund under these circumstances. I agree to forgo participating in this event if, on the day of or the day prior to the event, I feel sick with any sort of illness that may be spread to others. I understand that my entry in this event is non-transferrable, and I will not allow any other person to participate in the event under my name or registration. By submitting this entry, I acknowledge that I (or a parent or adult guardian for all children under 18 years of age) have read and agreed to the above release and waiver in full. |
Signature: _____________________________________ Date: _______________ (Parent's or guardian's signature if registrant is under 18) |
| Please make checks payable to "Karsten Brown" and mail to: Greasy-Gooney 10K c/o Karsten Brown 1195 South River Road Front Royal, VA 22630-8317 |
(Privacy note: Your personal information will be kept private and will not be shared with anyone. The race director sends out one or two e-mails each year to promote the Greasy-Gooney 10K and a few other races in the area; you are free to specify above whether or not you want us to send you such e-mails.) |
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| The Greasy-Gooney 10K Web pages are maintained by Karsten Brown. |