Rikki's Refuge 5K Online Entry Form

Lake Anna State Park, Saturday, November 7, 2015, 9:00 AM, $25.00 entry fee    Click here for more race info

All participants must acknowledge and sign the following waiver form:

WAIVER: In consideration of my entering the Rikki’s 5K Run/Walk, I hereby waive and release any and all claims for damage and/or injury that I, or anyone acting in my behalf, may have against the competition and all its sponsors, including, but not limited to Lake Anna State Park, Life Unlimited of Virginia, Inc. (Rikki’s Refuge), and/or any and all sponsors, volunteers, employees, corporations and directors thereof. I verify I am physically fit and have trained for this event. I grant full permission to any and all race organizers, sponsors, volunteers, employees and/or their representatives to transport me to the nearest physician or hospital for medical treatment and agree to allow for immediate first aid, if and when deemed necessary. I grant permission to any and all race organizers, sponsors, volunteers, employees and/or their representatives to photograph and/or videotape my participation in the race, and to use any photographs and/or videotapes for any legitimate purpose. If the race participant is a minor or otherwise unable to enter into a legal contract, I am signing as responsible parent or legal guardian.

Watch this space for error and informative messages

Please agree to the above waiver by entering your name(s) in the boxes below, and checking the box to acknowledge that this is your true, digital signature. * - required

*I acknowledge my digital signature
I acknowledge my digital signature
Runner information:
If mail should be addressed to parent/guardian/etc.
Male Female
Race day registrations not guaranteed a T-shirt!
After completing your PayPal transaction, please make sure
that you use the PayPal "Return to Rikki's Refuge" option
to navigate back to this page -- otherwise, you will not
get your official confirmation email -- nor will the race
organizer!
Click to sign up
and pay with
PayPal,
online check or
credit card