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Date: Saturday, December 1st 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 finished Fee for each race: $15.00 (Make checks made payable to: Appomattox 4-H Interstate Exchange Club ) *Inclement Weather Date: Saturday, December 8th
Return registration forms to 4-H Extension Office (behind courthouse) 352-8244. If you need more information you can also email Bonnie Tillotson at email@example.com They can also be mailed to: VCE – Appomattox P.O. Box 488 Appomattox, VA 24522 ****** Return registration by November 24th to get a race T-Shirt****** Name:________________________________________________________
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 (to be run twice for 5K) consists of rolling hills, all paved roads, **roads will remain open** and traffic will be controlled 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 Cooperative Extension to use such reproductions for educational and publicity purposes .I understand that some of the above information is 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 for damages I / my child may have against Virginia Cooperative Extension, sponsors, race directors, and any other parties involved in this race for any injuries suffered by me/my child during this event. I further state I/my child is in proper physical condition to compete in this race.
Signature of Participant or Parent / Guardian
Virginia Cooperative Extension programs and employment are open to all, regardless of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, or marital or family status. An equal opportunity/affirmative action employer.