RegisterOnline - Dyersburg-Dyer County Union Mission

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Dyersburg-Dyer County Union Mission

P.O. Box 179 (38025), 213 West Cedar St., Dyersburg, TN 38024 Ph 731-285-0726

MISSION MARCH Registration Form ** YOU ARE ONLY REGISTERED AFTER PAYING THE FEES ON THE NEXT PAGE **

YOU MUST SUBMIT A SEPARATE REGISTRATION FOR EACH RACE! Required information is identified with a *.
*Name (Last, First, Middle):
Address:
City:
State:
Zip:
Birthdate (MM/DD/YYYY):
Phone:
Gender:	Male Female
Shirt Info	T-Shirt (S M L XL XXL XXXL) No shirt (Second race is half price without shirt) Youth T-Shirt (XS S M)
Shirt Size:	X-Small Small Medium Large X-Large XX-Large XXX-Large
*Race:	5K {$12} ($15 if paid after Oct. 10) Ghost Participant {$15} 5K Wheelchair {$12} ($15 if paid after Oct. 10) 1-mile Youth Race {$8} ($10 if paid after Oct. 10) 2-Mile Walk {$12} ($15 if paid after Oct. 10) The Dyersburg Mile {$10} ($12 if paid after Oct. 10)
Recruited By:
* Emergency contact name and phone:
N O T I C E : Registrations dated before midnight October 10, 2011 will receive preferred pricing (the first price listed in { } next to the race selection). The second price (in parentheses) will be charged for all entries past that time. Online registration deadline is 11:59 p.m., Thursday, October 13, 2011.

*Confirmation E-mail Address:
Don't miss the opportunity to sign up for your favorite team! Team members may participate in either 5K, 2-mile and/or 1-mile or Dyersburg Mile or be a Ghost Participant. They may enter more than one event or represent more than one team. Each event must have its own registration, and fee must accompany each registration. YOU MUST NOTE THE NAME OF YOUR TEAM AFFILIATION BELOW, OR CREDIT CANNOT BE GIVEN TO YOUR TEAM. * The largest team, not the fastest team, wins. * A nice traveling plaque will be awarded to each team with the most registered. There will be 1st and 2nd place plaques awarded in each division. You Must Pre-Register For Team Competition By October 10.
Team Name:
Type of Team:
I, individually, (and/or as parent and/or guardian of the named minor) for and in consideration of the acceptance of this application to participate in the events herein for myself, my heirs, assigns, executors, and administrators (and/or the heirs, assigns, executors, and administrators of the named minor), do hereby release, remise, waive, surrender, and forever discharge and agree to indemnify and save harmless the DYERSBURG-DYER COUNTY UNION MISSION and all other sponsoring groups of the events herein, together with all of their officers, agents, officials, directors and employees, from any and all liability, claims, demands, actions or causes of action whatsoever, arising out of or related to any injury, illness, loss or damage, including death relating to participation in the aforesaid events. I am aware the activities may be hazardous and I do freely and voluntarily assume all the risks, known or unknown, incident to participation in these events. I further state and represent that I (or the named minor) am in proper physical condition and am sufficiently trained to participate in this event. I also give my permission for the free use of my name and/or picture in any advertisement or other account of these events.
By entering your name and the date in the Signature Box, you accept the terms of the release .
*Signature:
After you SUBMIT your registration information, select the DONATE button on the next screen to pay the race fees. REMEMBER! YOU ARE NOT REGISTERED UNTIL THE FEES ARE PAID! After your information is submitted, corrections can only be made by calling 731-285-0726.