2021 Derby Fair 5K
Registration Form
Make Checks Payable to: Return To: Derby Fair 5K
The First Church of Evans PO Bx 364
Derby, NY 14047
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Last Name First Name
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Number & Street
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City/Town State Zip Code
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Sex Age Phone Number 5K 1 Mile Fun Run Shirt S, M, L, XL
Release: I realize that racing can be dangerous and do hereby release and discharge from liability The First Church of Evans, the Town of Evans, the race organizers, volunteers and sponsors for any and all injuries suffered during this race. I attest and verify that I am physically fit and have sufficient training for this event. I hereby certify that I have read and fully understand this release and agree to all of its aforesaid terms, understanding this release is a legally binding agreement.
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Signature Parent Signature (If under 18)
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Date
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Location: The First Church of Evans
7431 Erie Rd. (Rte. 5)
Derby, NY 14047
Distance: 5K
Date: September 11, 2021
Time: 5K Run 10am
1 Mile Walk 10am
Entry Fee: Students $10
All Others - $15 Pre-Registered by 9/8/21
$17 Race Day
Awards: Overall Male & Female; Medals to top 3 in age groups:
10 & Under; 11-14; 15-19; 20-24; 25-29; 30-34;
35-39; 40-44; 45-49; 50-54; 55-59; 60-64; 65-69;
70-74; 75 and Over
Packets: Race Day, starting at 8:30am
Giveaways: Custom T-Shirts to first 80 entrants
Hot Dog & Pop
Course Route: Fast flat down and back course along Sturgeon Pt. Rd.,
starting and ending at church.
Certification: USATF #NY11053JG
Additional: Natalie Ridge 716 517 1252
[email protected]