South Central Classic Flyer

4^th Annual 5K Run/Walk

Registration by September 19^th, 2009 guarantees a t-shirt!

Make Checks payable to "Wellness Center", and designate check to South Central Classic (SCC).

Mail or hand deliver this registration form to: Wellness Center

P.O Box 607

Laurel, MS 39440

Name: _______________________________________ Sex: M F

Address: _____________________________________ Phone: ( ) _____________

_____________________________________ Age on Race Day_________

Email (optional) ________________________

T-shirt size: M L XL XXL Please Check one option:

___ Wellness Center Member $12

___ Pine Belt Pacer $12

___ Pre-Registration $15

___Day of Race (everyone) $20

Waiver and Release: I am in excellent health, adequately trained and fit to participate in this race. In consideration of the acceptance of the entry, I agree my participating in this event is without assumption of any kind of responsibility by the SCRMC Wellness Center, SCRMC agents, servants, employees, trustees, the race directors, and other sponsors of this race assigns for any and all injuries or death suffered by me in this event. I understand all entries are final, with no refunds, and that the race directors reserve the right in the event of an emergency or local/national disaster to cancel the race or to change the day and/or time to a later date and that in the event of cancellation there is no refund of entry fees. I knowingly assume all risk involved in this event. I further give permission for the use of my name and or photograph in post race publicity.

Signature: __________________________________ Date: _____________

Guardian if under 18 __________________________ Date: _____________