ist annual debbie burchettstorage.googleapis.com/wzukusers/user-12848592/documents/... · web...

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Course: USATF certified and sanctioned 5K road course through Clemmons West Subdivision. Easy to moderatre course with only a couple of mild hills. Start and finish at Clemmons West Swimming Pool. Finish line managed by Twin City Track Club. Directions: I-40 West to Clemmons exit. Left at light, Clemmons West Pool is approximately 1 ¾ miles on right. Parking: Across Middlebrook Drive at Hayward Industries parking lot. Registration: Via mail or www.active.com $25.00 Until May 9 $30.00 After May 9 and race day $12.00 Fun run/walk until May 9 $15.00 Fun run/walk after May 9 T-Shirts: T-Shirts guaranteed to the first 200 entrants (5K & Fun run/walk). Packet Pick-up: Friday, June 5, 5:30 pm – 8:00 pm at Clemmons United Methodist Church Fellowship Hall, 3700 Clemmons Road (US 158) Race day 7:00 am – 7:45 am at Clemmons West Pool Shelter. Start Times: Fun run/walk, 8:15 am. 5K, 8:30 am Awards:* Awards immediately following the completion of the 5K at the pool shelter as follows: Overall: Top 3 males and females And male and female master and grand master Age Groups: Top 3 males and females in each division. 12 & under, 13-19, 20- 24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-65, 66 & over. Fun Run: Top male and female 13 and up. Top male and female 12 and under. * No duplication of awards Post-Race Refreshments: Refreshments will be available beginning approximately 9:00 am at the pool shelter. Additional Information: Call 336-766-0385 Name:_________________________________ Race entering: 5K____ Fun run/walk:____ Address:________________________________ Phone:_____________ City:_________________________ State:____ Zip Code:___________ E- Mail :___________________ T-Shirt Size: M__ L__ XL__ Sex: M__ F__ Birth Date:____________ Age on Race Day:_____ Entry Fees: 5K before May 9, $25.00, after, $30.00 Make checks payable to: SFC 5k Fun run/walk, before May 9, $12.00,after,$15.00 Total Enclosed:$ ______ RACE WAIVER: I know that running a road race is a potentially hazardous activity. I should not enter and run unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all risks associated with running in this race, including, but not limited to, falls, contact with other participants, the effects of the weather including high heat and humidity, traffic, and the conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I for myself and anyone for whom I am entitled to act, waive, release, and will hold harmless the Clemmons Stride for Courage 5K committee, all other sponsors, and all the agents, employees, officers, directors and volunteers working for those entities from all claims and liabilities of any kind arising out of or related to my participation in this race. I understand that headphones, baby joggers or strollers, roller skates and dogs are not allowed in this event unless explicitly authorized by the race organizer. Signature (parent or guardian if under 18): _______________________________________________Date:__________ Emergency Contact: Name:_______________________________ Phone:_______________ Mail to : Stride for Courage 5K, 732 La Vale Drive, Clemmons, NC 27012

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Page 1: Ist Annual Debbie Burchettstorage.googleapis.com/wzukusers/user-12848592/documents/... · Web viewUSATF certified and sanctioned 5K road course through Clemmons West Subdivision

Course: USATF certified and sanctioned 5K road course through Clemmons West Subdivision. Easy to moderatre course with only a couple of mild hills. Start and finish at Clemmons West Swimming Pool.

Finish line managed by Twin City Track Club.

Directions:I-40 West to Clemmons exit. Left at light, Clemmons West Pool is approximately 1 ¾ miles on right.

Parking: Across Middlebrook Drive at Hayward Industries parking lot.

Registration: Via mail or www.active.com

$25.00 Until May 9

$30.00 After May 9 and race day

$12.00 Fun run/walk until May 9

$15.00 Fun run/walk after May 9

T-Shirts: T-Shirts guaranteed to the first 200 entrants (5K & Fun run/walk). Packet Pick-up: Friday, June 5, 5:30 pm – 8:00 pm at Clemmons United Methodist Church Fellowship Hall, 3700 Clemmons Road (US 158) Race day 7:00 am – 7:45 am at Clemmons West Pool Shelter.

Start Times:Fun run/walk, 8:15 am. 5K, 8:30 am

Awards:*Awards immediately following the completion of the 5K at the pool shelter as follows:

Overall:Top 3 males and femalesAnd male and female master and grand master

Age Groups: Top 3 males and females in each division. 12 & under, 13-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-65,66 & over.

Fun Run: Top male and female 13 and up. Top male and female 12 and under. * No duplication of awards

Post-Race Refreshments: Refreshments will be available beginning approximately 9:00 am at the pool shelter.

Additional Information: Call 336-766-0385

The Debbie Burchett Endowment Fund

The Debbie Burchett Endowment Fund is a permanent endowment that was created in the

Nam

e:__

____

____

____

____

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____

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irth

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____

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ace

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Ent

ry F

ees:

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ore

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9, $

25.0

0, a

fter,

$30.

00

M

ake

chec

ks p

ayab

le to

: SFC

5k

F

un ru

n/w

alk,

bef

ore

May

9, $

12.0

0,af

ter,$

15.0

0

T

otal

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lose

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____

_

RA

CE

WA

IVER

: I k

now

that

runn

ing

a ro

ad ra

ce is

a p

oten

tially

haz

ardo

us a

ctiv

ity. I

sho

uld

not e

nter

and

run

unl

ess

I am

med

ical

ly a

ble

and

prop

erly

trai

ned.

I ag

ree

to a

bide

by

any

deci

sion

of

a ra

ce o

ffici

al re

lativ

e to

my

abili

ty to

saf

ely

com

plet

e th

e ru

n. I

assu

me

all r

isks

ass

ocia

ted

with

run

ning

in th

is ra

ce, i

nclu

ding

, but

not

lim

ited

to, f

alls

, con

tact

with

oth

er p

artic

ipan

ts, t

he e

ffect

s of

th

e w

eath

er in

clud

ing

high

hea

t and

hum

idity

, tra

ffic,

and

the

cond

ition

s of

the

road

, all

such

ris

ks b

eing

kno

wn

and

appr

ecia

ted

by m

e. H

avin

g re

ad th

is w

aive

r an

d kn

owin

g th

ese

fact

s an

d in

co

nsid

erat

ion

of y

our

acce

ptin

g m

y en

try,

I fo

r m

ysel

f and

any

one

for w

hom

I am

ent

itled

to a

ct, w

aive

, rel

ease

, and

will

hol

d ha

rmle

ss th

e C

lem

mon

s St

ride

for

Cou

rage

5K

com

mitt

ee, a

ll ot

her

spon

sors

, and

all

the

agen

ts, e

mpl

oyee

s, of

ficer

s, di

rect

ors

and

volu

ntee

rs w

orki

ng fo

r th

ose

entit

ies

from

all

clai

ms

and

liabi

litie

s of

any

kin

d ar

isin

g ou

t of o

r re

late

d to

my

part

icip

atio

n in

this

ra

ce. I

und

erst

and

that

hea

dpho

nes,

bab

y jo

gger

s or

stro

llers

, rol

ler

skat

es a

nd d

ogs

are

not a

llow

ed in

this

eve

nt u

nles

s exp

licitl

y au

thor

ized

by

the

race

org

aniz

er.

Sign

atur

e (p

aren

t or g

uard

ian

if un

der 1

8):

____

____

____

____

____

____

____

____

____

____

____

___D

ate:

____

____

__ E

mer

genc

y C

onta

ct:

Nam

e:__

____

____

____

____

____

____

____

_ Ph

one:

____

____

____

___

M

ail t

o : S

tride

for C

oura

ge 5

K,

732

La V

ale

Driv

e, C

lem

mon

s, N

C 2

7012

Nam

e:__

____

____

____

____

____

____

____

___

Rac

e en

teri

ng: 5

K__

__ F

un ru

n/w

alk:

____

Add

ress

:___

____

____

____

____

____

____

____

_ P

hone

:___

____

____

__C

ity:_

____

____

____

____

____

____

Sta

te:_

___

Zip

Cod

e:__

____

____

_ E

-Mai

l :__

____

____

____

____

_

T-Sh

irt S

ize:

M__

L__

XL_

_

Sex:

M__

F__

B

irth

Dat

e:__

____

____

__ A

ge o

n R

ace

Day

:___

__

Ent

ry F

ees:

5K

bef

ore

June

8, $

17.0

0, a

fter,

$20.

00

M

ake

chec

ks p

ayab

le to

: DB

BC

F

Fun

run/

wal

k, $

15.0

0

Tot

al E

nclo

sed:

$___

___

RA

CE

WA

IVER

: I k

now

that

runn

ing

a ro

ad ra

ce is

a p

oten

tially

haz

ardo

us a

ctiv

ity. I

sho

uld

not e

nter

and

run

unl

ess

I am

med

ical

ly a

ble

and

prop

erly

trai

ned.

I ag

ree

to a

bide

by

any

deci

sion

of

a ra

ce o

ffici

al re

lativ

e to

my

abili

ty to

saf

ely

com

plet

e th

e ru

n. I

assu

me

all r

isks

ass

ocia

ted

with

run

ning

in th

is ra

ce, i

nclu

ding

, but

not

lim

ited

to, f

alls

, con

tact

with

oth

er p

artic

ipan

ts, t

he e

ffect

s of

th

e w

eath

er in

clud

ing

high

hea

t and

hum

idity

, tra

ffic,

and

the

cond

ition

s of

the

road

, all

such

ris

ks b

eing

kno

wn

and

appr

ecia

ted

by m

e. H

avin

g re

ad th

is w

aive

r an

d kn

owin

g th

ese

fact

s an

d in

co

nsid

erat

ion

of y

our

acce

ptin

g m

y en

try,

I fo

r m

ysel

f and

any

one

for w

hom

I am

ent

itled

to a

ct, w

aive

, rel

ease

, and

will

hol

d ha

rmle

ss th

e D

ebbi

e Bu

rche

tt Br

east

Can

cer

Fund

, all

othe

r sp

onso

rs,

and

all t

he a

gent

s, e

mpl

oyee

s, of

ficer

s, di

rect

ors

and

volu

ntee

rs w

orki

ng fo

r th

ose

entit

ies

from

all

clai

ms

and

liabi

litie

s of

any

kin

d ar

isin

g ou

t of o

r re

late

d to

my

part

icip

atio

n in

this

rac

e. I

unde

rsta

nd th

at h

eadp

hone

s, b

aby

jogg

ers

or s

trolle

rs, r

olle

r sk

ates

and

dog

s ar

e no

t allo

wed

in th

is e

vent

unl

ess

expl

icitl

y au

thor

ized

by

the

race

org

aniz

er.

Sign

atur

e (p

aren

t or g

uard

ian

if un

der 1

8):

____

____

____

____

____

____

____

____

____

____

____

___D

ate:

____

____

__ E

mer

genc

y C

onta

ct:

Nam

e:__

____

____

____

____

____

____

____

_ Ph

one:

____

____

____

___

M

ail t

o : D

BB

CF

5K,

728

La V

ale

Driv

e, C

lem

mon

s, N

C 2

7012

Page 2: Ist Annual Debbie Burchettstorage.googleapis.com/wzukusers/user-12848592/documents/... · Web viewUSATF certified and sanctioned 5K road course through Clemmons West Subdivision

The Debbie Burchett Endowment Fund

The Debbie Burchett Endowment Fund is a permanent endowment that was created in the Spring of 2000 benefiting Cancer Services, Inc.to assist women undergoing cancer treatment. The fund was named in honor of Debbie Burchett for her inspiration and service to survivors in the Winston-Salem area with breast cancer.

The purpose of the fund is to provide financial support to survivors without adequate means to cover ancillary costs related to cancer treatment. These needs include prosthetic products, transportation, child care, home care and other related expenses, not normally reimbursed by medical insurance, or other private funds.

Through Cancer Services, Inc. eligible recipients are identified and grants are provided from the fund for distribution to those with essential needs.

Cancer Services, Inc. is a local non-profit organization serving Davie, Forsyth, Stokes, Surry and Yadkin counties, providing without charge, a full range of services for those living with cancer. Our services include:

Patient Advocacy and Information Medication & Financial Assistance Equipment, Supplies, Wigs, & Prosthesis Transportation to Treatment Peer Support for Survivors Survive & Thrive Wellness Groups &

Programs Healing Hands Clinics Lifestyle Programs for Risk-Reduction &

Survivorship

For additional information about Cancer Services check our website at:

www.cancerservicesonline.org Benefiting

Cancer Services, Inc.Debbie Burchett Endowment Fund

Clemmons, NC June 6, 2015