18TH ANNUAL LOUISBOURG RACE THROUGH TIME
2012 Run Nova Scotia Road Race Series – Race # 18
6:00pm – George D. Lewis School
Mail application and registration fee to: “Louisbourg Race Through Time”
CBRM Recreation Department (Rural Division)
7495 Main Street, Louisbourg, N.S., B1C 1H6
NAME: ______________________________________________________ RUN N.S. # (if applicable): _______________
ADDRESS: _______________________________________________________________________________________________
CITY: __________________________________ PROVINCE: _______________ POSTAL CODE: _________________
PHONE: ______________ GENDER: ______ DATE OF BIRTH: _______________ AGE (on race day): ______
EMAIL ADDRESS:________________________________ T-SHIRT SIZE: ____ (all runners receive a t-shirt)
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FEES ENCLOSED: Registration fee includes a meal & all runners will receive a t-shirt!
Non-Run N.S. Member Registration Fee: $22.00 ( ) *** Run N.S. Member Fee: $18.00 ( )
Additional Meal Tickets: ____ X $7.00 each = $____ (Note: Registration Fee Includes 1 meal ticket)
TOTAL MONEY ENCLOSED: $ _________ (Please make cheque payable to: Louisbourg Race Through Time)
PLEASE NOTE:
1) Pre-registration Deadline: Monday, August 13th, 2012. Registration received after this date will be charged an additional $10.00 late fee.
2) Race kits can be picked up on race day starting at 4:00pm at George D. Lewis School.
3) There will be a number of water stops, providing water only, situated along the route.
4) A listing of accommodations in the area will be available upon request.
Understanding of Risk and Release of Responsibility
I understand that participating in a road race is a potentially dangerous event. Further, the weather, footing and vehicle traffic conditions may be adverse and greatly increase the danger. I certify that I am medically fit to participate without risk to myself or others. I understand that I am totally responsible for my own safety.
In consideration of my being permitted to participate in the Louisbourg Race Through Time, I hereby remise, release and forever discharge, waive and save harmless, protect and indemnify the Louisbourg Road Race Society, Cape Breton Regional Municipality, CBRM Recreation Department, Athletics Canada, Athletics Nova Scotia, Sport Nova Scotia, Run Nova Scotia, any and all clubs, associations, sanctioning bodies, sponsors, participants, competitors, entrants and all respective agents, officials, volunteers, servants, and representatives from and against any and all kinds of action claims, costs and expenses and demands in respect of death, injury, loss or damage to my person or property howsoever caused as a result of my being permitted to attend or in any way take part prior to, during or subsequent to the Louisbourg Race Through Time, whether as an entrant, competitor, spectator or otherwise, notwithstanding that some may have been contributed to or occasioned by the negligence of any of the aforesaid, their agents, officials, servants or representatives. Further, I hereby grant permission to any of the above to disseminate photographs or other race result information to the public, through any medium they so choose, from time to time. All participants become event members of Run Nova Scotia for the duration of this event.
By submitting this entry, I acknowledge having read, understood and agreed to the above. This document will bind my heirs, executors, administrators, successors, and assigns.
Signature____________________________________ Date: ______________________
(Parent or Guardian, if runner is under 18 years of age)