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Name (please print)___________________________________ Age race day____________

Address_______________________ City________________ State________ Zip________

Phone______________ Running Club_____________________________

Gender ____ Date of birth____________ Your Best 50k ______________Is this your first ultra?________

Emergency Contact______________________ Emergency Phone___________

E-Mail Address___________________________ Vest Size____________(5 Year Vets)

Waiver and release: I agree to save, release, and keep harmless The Mangum Track Club, organizers of The Derby 50k, officials, participating sponsors, volunteers, and any other groups, agencies, or individuals involved with this event from all liability, claims, or demands for damages incurred by my participation in the The Derby 50k or any of its related parts. I realize that participating in a ultra is a sometimes risky and potentially hazardous endeavor and assume all responsibilities for my participation. I certify that I am properly trained and medically able to participate in this event. I realize that the race director has the right to refuse any entry and that decisions rendered by the race director whether in participation or finish results will be final.

Signature_______________________________________________ Date________________
(Parent or guardian if under 18)
 

Make check payable and mail the completed entry form to:

Mark Long
111 Carroll Street
Hamlet, NC 28345