Community 5K Splatter Run/Walk
Saturday, May 9, 2015
Entry Fees: Pre registration $25 per Adult; $30 on race day
Teens - $20; Kids - $10
On race day only check or cash accepted
First 100 to register will receive a “FREE” 5K T-Shirt
Proceeds to benefit Young Life and YoungLives (teen moms)
5K Splatter Run/Walk (Muddy Run Road) begins at 9:30am – 11:00am
Registration Time - 9:00am at Emerald Hill Elementary School parking lot. (Not sponsored by CCPS)
Event Description: Join us for the fifth annual tradition of the Young Life Community 5K Splatter Run/Walk. Enjoy being
splattered (nontoxic, water based paint) during the race and participate in the color throw "free for all" at the end. Wear
clothes that can get messy (color does wash out). Door prizes and Medal Ceremony held immediately following the run.
Registration Form:
I know that running a road race is potentially hazardous activity. I should not enter and run unless I am medically able and properly trained. I also know that
although it is unlikely, there may be traffic on the course route and I must watch for vehicles at intersections and on the roads. I also assume any and all other
risks associated with running this event including but not limited to falls, contact with other participants, the effects of weather including high heat and/or
humidity and the condition of the roads. I recognize wearing a portable listening device during the race is prohibited by the organizers.
Knowing these facts, and in consideration of your acceptance of my entry fee, I hereby for myself, my heirs, executors, administrators or anyone else who might
claim on my behalf, covenant not to sue, and waive, release, and discharge The Young Life Community 5k, Young Life Culpeper and any organization associated
with the race, and the local governments and police, volunteers, and any and all sponsors including their agents, employees, assigns or anyone acting on their
behalf, from any and all claims or causes of action (known or unknown, foreseen or unforeseen) for death, personal injury or property damage of any kind or
nature including those arising out of, their negligence in the course of, my participation in this road race and all other events and activities associated with this
race.
I give my permission for medical team evaluation, treatment, and transfer to an emergency facility if needed. I agree that race officials have the right to
remove me from the race and related activities if they are of the opinion that it is in my best interest or the best interest of the Young Life Community 5K that
I be removed. I further grant permission to the Young Life Community 5K and/or agents authorized by them to use any photographs, videotapes, motion
I have read the foregoing and certify my agreement by signing below. (Parent or guardian must sign below if applicant is under 18 yrs old).
SIGNATURE OF PARTICIPANT (Or signature of parent/guardian if participant is under 18 years old):
_______________________________________________ PRINT NAME: _______________________________
First Name______________________________________
Last Name______________________________________________
Male _____ Female _____ Age group: ___13 & under ___14-19 ___20-29 ___30-39 ___40-49 ___50-59 ___60 & over ___ Stroller Roller
Address: _______________________________________ Phone Number: ________________ Email: ______________________
In case of an emergency contact: __________________________________________ Phone #: ___________________
Registration fee enclosed (Checks payable to Young Life) $____________
Guaranteed t-shirt size if registered by April 15th (Circle Size) Adult - S M L XL XXL
I wish to make an additional donation in the amount of $____________
Total Amount Enclosed $____________
A Special “Thank You” to our 5K Sponsors
Culpeper Young Life
PO Box 803, Culpeper, VA 22701
[email protected]
540 219-8043