3.1.2014 - Newton, MS.

1. LOOSE CABOOSE 2014
5K Run/2 Mile Walk/Fun Run/Bike Ride
Saturday, March 1, 2014
Name_________________________________________________________________________________________
Address_______________________________________________________________________________________
City________________________________ State________________________ Zip __________________________
Age Race Day_________________
Birthday__________________________________________________
Sex: M_________
F__________
Phone_____________________
Event: (circle one)
5K Run
2 Mile Walk
Shirt Size ________________
Kids Fun Run
Kids Bike Ride
In consideration for the acceptance of my registration as a participant in the above entitled event and with the understanding that my participation
in the event is only on condition that I enter into this agreement, for myself my heirs, and assigns, I hereby assume the inherent and extraordinary
risks involved in this event and any risks inherent in any other activities connected with this event in which I may voluntarily participate. I
expressly assume the risk of and accept full responsibility for any and all injuries (including death) and accidents which may occur as a result of
my participation in this event and release Newton Chamber of Commerce, City of Newton, and each of their employees, volunteers, and
representatives. I hereby waive any claim I may hereafter have as a result of any and all injury to my person or property as a result of my
participation in this event, and any other activities connected to this event in which I voluntarily participate. I hereby agree to indemnify all of the
above named persons for any and all claims including attorney fees and costs which may be brought against any of them by anyone claiming to
have been injured as a result of an injury to me or my property which may occur as a result of this event. I certify that I have read and fully
understand this release. I am of lawful age and legally competent to make this agreement.
Signature ________________________________________________________Date________________________
Parent/Guardian __________________________________________________ Date _______________________
(If under 18 years of age)
5K/2
Mile
Walk
Registration
–
7
am
Race
Begins
–
8
am
Pre-­‐registration
Fee
-­‐
$20
Day-­‐of
Registration
-­‐
$25
Kids
Fun
Run
Ages
12
&
Under
All
participants
will
receive
a
t-­‐shirt
and
medal!
Race
is
approximately
3/10
of
a
mile.
There
will
be
an
award
for
best
costume!
Start
Time
–
10
am
Registration
-­‐
$10
Awards
5K
–
Overall
Male
and
Female
–
1st,
2nd
&
3rd
Walk
–
Overall
Male
or
Female
–
1st
All
preregistered
participants
WILL
receive
a
t-­‐shirt!
Kids
Bike
Ride
Ages
12
&
Under
All
participants
will
receive
a
t-­‐shirt
and
medal!
Race
is
approximately
1/2
of
a
mile.
Look
out
for
fun
obstacles
along
the
way!
Start
Time
–
2
pm
Registration
-­‐
$10
Helmets
MUST
be
worn!
Forms and Information:
Newton Chamber of Commerce 601-683-2201
Mail or Drop-Off Registration Forms to:
Newton Chamber of Commerce
128 South Main Street, Newton, MS 39345