Email _________________________________________________________________________________________________
Last Name _____________________________________________________________________________________________
First Name ____________________________________________________________________________________________
Address/Apt. #__________________________________________________________________________________________
City_________________________________________________State __________________ ZIP________________________
Country_____________ Projected Finish Time:15K _______ 5K _________ Half Marathon ___________ 8K ____________
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XS |
S |
M |
L |
M |
F Actual Age on Race Day _____________ Date of Birth _______________ T-shirt Size |
XL |
XXL |
XXXL |
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Gender Speci |
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Work Phone _______________________________________ Home Phone________________________________________
F O R R E G I S T R A T I O N C O N F I R M A T I O N , A N E M A I L A D D R E S S M U S T B E P R O V I D E D
In consideration of my entry being accepted in the Publix Gasparilla Distance Classic 15K, 5K, Half Marathon, 8K, Michelob Ultra Challenge, Michelob Ultra Amber Challenge, or Michelob Ultra Lime Cactus Challenge, I, intending to be legally bound, do hereby, for myself, my heirs, executors, and assigns, waive, release and forever discharge any and all rights and claims for damages that I may have or which may hereafter accrue to me against the Gasparilla Distance Classic Association Inc., Publix Super Markets, the City of Tampa, Hillsborough County or any subsidiary or political subdivision thereof, its or their respective o, agents, representatives, successors, assigns and sponsors for any and all damages that may be sustained and suered by me in connection with my association with or entry or participation in the Gasparilla Distance Classic events. I understand that a physical examination is not required to qualify to run this event and that all competitors participate at their own risk. (If in doubt as to your physical condition to engage in an event as strenuous as these races, it is strongly recommended that you seek the advice of a competent physician.) I also understand that in the event these races cannot be held as scheduled because of an act of God or circumstances beyond control the race is not liable to refund any money paid by me to participate. I release the rights to any and all photographic material, including and computer information the GDCA may wish to release for this event without obligation to me. All persons
under 18 years of age must have written consent of parent or legal guardian to compete in the abovementioned events. I, the undersigned parent or guardian, hereby consent to the applicant's participation and waive and release all rights and claims for damages as is more fully set forth above. I agree to drug testing in accordance with The USA Track and Field and IAAF Rule 144 if I place in the Top 25 overall men and women. I also hereby consent to permit emergency treatment in the event of injury or illness. Gasparilla Distance Classic reserves the right to reject entry.
Signature____________________________________ Parent Guardian (if under 18) ________________________________
Emergency Contact _______________________________________________ Contact Phone ________________________
RACE FEES |
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POSTMARKED BY 05/31/2016 |
15K __________________________________________________ |
$35 |
5K Run (5 years & older) ______________________________________ |
$25 |
5K Walk (5 years & older) _____________________________________ |
$25 |
5K Stroller Roll (5 years & older) ______________________________ |
$25 |
5K Stroller Roll (children 4 years & under ) ______________________________ |
$5ea |
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Child Name/Age ______________________________________________________ |
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Child Name/Age ______________________________________________________ |
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Child Name/Age ______________________________________________________ |
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Gasparilla Half Marathon |
_________________________________ |
$75 |
Gasparilla 8K ___________________________________________ |
$30 |
Michelob Ultra Challenge * _________________________________ |
$190 |
(RUN THE 15K, 5K, HALF MARATHON AND 8K) |
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Michelob Ultra Amber Challenge * |
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$160 |
(RUN THE 15K, 5K AND HALF MARATHON) |
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Michelob Ultra Lime Cactus Challenge *__________________ |
$90 |
(RUN THE 15K AND 8K) |
*Challenge Jackets are NOT Gender Speci |
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Jacket Size:___________________________ |
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TOTAL AMOUNT DUE: |
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$ ___________ __ |
USAA Military Division (check your branch) |
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Army |
Navy |
Marines |
Air Force |
Coast Guard |
National Guard |
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Make checks payable in U.S. funds to: GDCA and mail to:
GD CA, P . O. B O X 1881, T A MPA , FL 33601- 1881
F O R M O R E I N F O R M A T I O N O R T O R E G I S T E R O N L I N E ,
V I S I T W W W . T A M P A B A Y R U N . C O M O R C A L L ( 8 1 3 ) 2 5 4 - 7 8 6 6
ALL E NTR Y FE E S AR E NON- R E FUNDAB LE AND NON TR ANS FE R AB LE .
