Packet Pickup Race Date: March 19, 2016 Register Online at www

Packet Pickup
Print Form
March 14th - 18th
Fleet Feet at Heights Village
11:00am - 7:00pm
Race Date: March 19, 2016
Sloss Furnaces ~ Birmingham, AL
Register Online at
www.RunSignUp.com
Rumpshaker 5K
& 1 Mile Fun Run
Race Site: Sloss Furnaces
Website: www.Rumpshaker5K.com
Race Day Registration:
6:00am - Registration Opens
7:15am - 5K Registration Closes
8:00am - 5K Start
8:30am - 1 Mile Fun Run Registration Closes
9:00am - 1 Mile Fun Run
Team:
Team:
Individual:
Register
9:00am - Awards
by March 5th March 6 - 12 March 13 - 18 March 6 - 18
1 Mile Fun Run
Race Benefits:
Colorectal Cancer Awareness
Race Day:
March 19th
Do you want a
timing chip?
$18 / $15 Team
$18
$20
$20
$22
n/a
5K Individual
$25
n/a
n/a
$30
$35
$3.50 Extra
5K Team Member / Captain
$20*
$25*
$30*
n/a
n/a
$3.50 Extra
$25 / $20 Team
$25*
$30*
$30*
n/a
n/a
My Rump is Sleeping In
I Plan to Run the 5K
I Plan to Walk the 5K
Total:
Timing Chip: $3.50 Extra, add fee above to know how fast you ran or walked.
* If a Team has LESS than 5 members by 03/05/16, each
member will need to pay the EXTRA $5
for Individual entry fee at packet pickup.
Team Name:
Captain Phone #:
Team Captain:
I am the Team Captain. (For faster processing, Online Team Captain registration is recommended.) www.RunSignUp.com
I would like to be recognized as a colorectal cancer survivor at the race
Additional Donation to Rumpshaker, Inc - Colorectal Cancer Awareness (Non-profit 501(c)3)
Make Checks Payable and Mail to: Rumpshaker 5K P.O. Box 13023
Questions: [email protected]
Birmingham, AL 35202
Last Name:
First Name:
Street Address:
City:
State:
Phone Number:
T-Shirt Size:
Male
Female
Zip:
Age:
Total:
DOB:
Email:
Youth Medium
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Emergency Contact Information:
Contact Name:
Phone Number:
Release Waiver:
I know that running a road race is a potentially hazardous activity. I should not enter and run the Rumpshaker 5K unless I am medically able and properly
trained. I agree to abide by any decision of a race official or Police relative to my ability to safely complete the run. I assume all rights associated with running the
event including but not limited to falls, contact with other participants, the effects of the weather including high heat and/or humidity, traffic and conditions of the
road. All such risks are known and appreciated by me. Having read this waiver and knowing the risks and in consideration of you accepting my entry, I, for myself
and anyone entitled to act on my behalf, waive and release the Rumpshaker 5K , Championship Racing, LLC, the City of Birmingham, all sponsors, volunteers,
together with their employees, contractors, subcontractors, directors, officers, agents, attorneys, and representatives from all claims of liabilities of any kind or
character arising from my participation in this event or any related activity even though liability may arise from negligence or carelessness on the part of the
persons or organizations named in this waiver and release. I also am fully aware, whether same be caused by negligence or fault, that baby strollers, baby
joggers, wheels of any kind (except competitive wheelchairs), animals and headphones are strictly prohibited and I agree not to have them on the course. I
consent to the use of photographs, video, film and sound recordings of all Rumpshaker 5K Run events for all legitimate purposes, further, I consent to the use of
my image and/or likeness in any photographs, video, or sound records in or around the Rumpshaker event in any manner whatsoever. I give permission to be
contacted by interested media. I understand that the entry fee is non-refundable and non-transferable. I have read the entry information provided for the
event and certify my compliance by signature below. This is a Release of Liability Waiver.
Promoted By
Signed By (Guardian signature if under 18)
Date: