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2012 Clover Christmas Classic Registration Form

2012 Clover Christmas Classic Registration Form

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Published by Bonnie Tillotson

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Published by: Bonnie Tillotson on Oct 10, 2012
Copyright:Attribution Non-commercial


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Clover Christmas Classic 5K And Youth Mile
Date: Saturday, December 1
 Location: Main St. Appomattox (by Visitor’s Center)Start Time for 5K: 9:00 am (Arrive early enough to get number)Youth Mile to start after 5K race is finishedFee for each race: $15.00
(Make checks made payable to: Appomattox 4-H Interstate Exchange Club )
*Inclement Weather Date: Saturday, December 8
 Return registration forms to 4-H Extension Office (behind courthouse) 352-8244. If you need  more information you can also email Bonnie Tillotson at btillots@vt.eduThey can also be mailed to: VCE – Appomattox P.O. Box 488 Appomattox, VA 24522
****** Return registration by November 24
to get a race T-Shirt ******
First Last
Address: ____________________________________________________________________ Age on race day: __________ Gender: (M) (F) Shirt size: Youth (S) (M) (L) Adult (S) (M) (L)Birth date: ____/_____/______ E-Mail: _____________________________ Youth Mile age groups:
7 - 8, 9-10, 11- 13 (Parents are welcome to run with their child)
5K Age groups:
13 & under, 14-19, 20-29, 30-39, 40-49, 50-59, 60 & over.Awards to the top 3 M/F in each age group. Course: Start / Finish Main St. Appomattox: the loop course (tobe run twice for 5K) consists of rolling hills, all paved roads, **roads will remain open** and traffic will becontrolled by volunteers.
Virginia Cooperative Extension periodically uses photographs or video or audio footage or testimonials of 4-H members for local, regional, or state publicity or educational purposes. By my signature below I give permission for Virginia CooperativeExtension to use such reproductions for educational and publicity purposes .I understand that some of the above informationis considered private. This information will be used for programming purposes and given to people responsible for each program.
Signature of Participant or Parent/Guardian* _______________________________________ Date: ______________________ 
Wavier: I hereby for myself, my family, my heirs, executors, waive and release any and all my rights and claims fordamages I / my child may have against Virginia Cooperative Extension, sponsors, race directors, and any other partiesinvolved in this race for any injuries suffered by me/my child during this event. I further state I/my child is in properphysical condition to compete in this race.

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