2003 Entry Form
Race Date Is: July 12th, 2003
Early Registration Must Be Received By: July 9, 2003
Last Name: _______________________________ First Name: ________________________ M.I. ____
Address: ________________________ City: ___________ State: _______ Zip Code: _____________
Daytime Phone: __________-__________-_____________ E-Mail: _____________________________
Sex: _____________ Age: ______________ Date of Birth: ___________________________________
Please Circle The Event You Will Participate In: 5k Run (start 9:20 a.m.) 5k Walk (start 9:20 a.m.)
Please Make Check Payable To: Entry Fee- Early Registration Without T-shirt Is: $10.00 per event
Big Beaver Volunteer Fire Company Entry Fee- Early Registration With T-shirt Is: $12.00 per event
Day of Race- Registration Without T-shirt Is: $12.00 per event
Day of Race- Registration With T-shirt Is: $14.00 per event
Please Circle T-shirt Size: (Small) (Medium) (Large) (XL) (XXL)
Do Not Staple Checks To Entry Form.
One Name Per Entry. All Entry Forms
The Entry Fee Is Not Deductible. Must Be Signed
Door Prizes!! Grand Prize- Holiday Inn Weekend Night Stay for Two, including Sunday Breakfast!!
Refreshments and Awards Presented In-Doors After Race
First Aid courtesy of Chippewa Volunteer Fire Company Q.R.S.
Timing and Water on Course
Traffic Controlled Course
One Award per Participant
Awards By Age Group to 1st, 2nd, and 3rd place Men’s Finishers for 5k Run: 9 and Under, 10-14, 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75 and over.
Awards By Age Group to 1st, 2nd, and 3rd place Women’s Finishers for 5k Run: 9 and Under, 10-14,
15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75 and over.
Awards To Top Three Over-All For Men and Women 5k Run Participants
Awards to 1st, 2nd and 3rd place finishers Men and Women for 5k walk.
Race waiver and release (must be signed by participant): I understand that my consent to these provisions is given in consideration of the acceptance of this registration and for being permitted to participate in this event. I am a voluntary participant in this event, and in good physical condition. I know that this event is a potentially hazardous activity and I hereby assume full and complete responsibility for any injury or accident which may occur during my participation in this event or while on the premises of this event, and I hereby release and hold harmless and covenant not to file suit against the Big Beaver Boro Volunteer Fire Company, Big Beaver Borough, its local affiliates and any affiliated individuals, The State of Pennsylvania, its local affiliates and any affiliated individuals, any race sponsors and their agents and employees, and all other persons or entities associated with this event (the “releasees”) from any loss, liability or claims I may have arising out of my participation in this event, including personal injury or damage suffered by me or others, whether same be caused by falls, contact with participants, conditions of the course, negligence of the releasees or otherwise. If I do not follow all the rules of this event, I understand that I may be removed from the competition. I give my full permission to the Big Beaver Volunteer Fire Company and its local affiliates and races and their sponsors and corporate sponsors to use any photographs, videotapes, or other recordings of me that are made during the course of this event.
(Parent or Guardian IF PARTICIPANT IS UNDER AGE 18) Date
Mail Entry Forms To: Big Beaver Volunteer Fire Company- 621 Friendship Road, Darlington, PA 16115
CONTACT NUMBERS: 724-827-2416 AND 724-827-2411
DIRECTIONS: From Route 51(Constitution Blvd.) in Chippewa, PA (Burger King Intersection), Take Shenango Road to S.R. 551 (Wallace Run Road) Approx. 2 ˝ miles, Follow Posted Signs to Fire Hall.
From S.R. 351 and 18 in Koppel, PA. Travel South on 18 toward Beaver Falls (approx. 3 miles) to S.R. 551 (Wallace Run Rd.), follow S.R. 551 to intersection of S.R. 551 and Shenango Rd., Follow signs to Fire Hall.