Race time 10:00 am Registration Form

Race time 10:00 a.m.
Registration Form
Register online at www.augustaregionalspca.org/furry5k
Online and hand-delivered pre-registration ends at midnight on December 28th
Mailed registrations must be postmarked on or before December 20th
Mail Entry Form with check to:
Augusta Regional SPCA
P.O. Box 2014
Staunton, VA 24402
or drop off at:
The Augusta Regional SPCA
33 Archery Lane
Staunton, VA 24401
Phone: 540.885.7722
$20 Advance Registration Fee from Sept. 8 - Oct. 15, $25 from Oct. 15 - Dec. 31
$30 on day of race (race day registration 9-9:45 am)
Registration includes commemorative long-sleeved t-shirt.
(*A minimal number of extra shirts may be available after advanced registration, but are not guaranteed.)
Make checks payable to Augusta Regional SPCA.
Age must be provided to
be eligible for any awards
Participant Name: ______________________________________________________________ Age on Race Day:_____________
Address:____________________________________________________________________________________________________
City:________________________________________________________State: ____________________ Zip:____________________
Email:______________________________________________________________________________________________________
Phone: _____________________________________________________________________________________________________
Would you like to register your dog as a runner? If so, please provide his/her name and age:
Dog Name: _____________________________________________________________________ Age on Race Day:_____________
For Runner/Walker:
Sex (circle one): M F
T-shirt Size (circle one):
Youth MEDIUM
Adult Adult Adult Adult Adult SMALL MEDLARGE XL XXL
Race packets must be picked up by end of race or will be forfeited
Waiver Statement:
I, and my heirs, in consideration of my participation in the Augusta Regional SPCA’s Furry 5k, on January 1, 2015 in Staunton, VA hereby release the
ARSPCA, its officers, employees and agents, and any other people officially connected with this event, from any and all liability for damage to or loss of
personal property, sickness or injury from whatever source, legal entanglements, imprisonment, death, or loss of money which might occur while participating in this event.
Specifically, I release said persons from any liability or responsibility for my physical condition, for the condition of selection of course route which may include traversing unrestricted roads, speed bumps, gravel, walkways and for the presence or actions of any other persons or participants. I am aware of the
risks of participation, which include, but are not limited to, the possibility of injury, sprained muscles and ligaments, broken bones and fatigue. I hereby
state that I am in sufficient physical condition to accept a rigorous level of physical activity. I understand that the event does not provide medical coverage
for me. I verify that I will be responsible for any medical costs I incur as a result of my participation.
______________________________________________________________________________________________________________
Participant Name
Date
______________________________________________________________________________________________________________
Parent’s Signature
(ONLY if participant is under the age of 18)
Date