This document is a registration form for the Loop the Lake 5K run/walk that will take place on May 30, 2015 at Lake Blackshear Resort & Golf Club in Cordele, GA. Proceeds from the event will benefit GraceWay. Participants can register online or by mailing in this form along with payment. Early registration is $20-25 depending on the event and race day registration is $25-30. The form collects information like name, address, age, gender, t-shirt size and includes a waiver releasing the event organizers from liability.

1. SATURDAY,
MAY 30, 2015
Lake Blackshear Resort & Golf Club
2459-H US-Highway 280 West
Cordele,GA 31015
proceeds benefitpresented by
Register online: www.bit.ly/LTL2015
www.loopthelake.com e: raceloopthelake@gmail.com p: 229-446-4550
Make checks payable to:
GraceWay
Attn: Loop the Lake
P.O. Box 32
Albany, GA 31702
Are you a member of a team?
Yes ___ No ___ If yes, name of team: __________________________
Early registration:
___ $20 - 1 mile walk/run/stroller roll
___ $25 - 5K (children & adults)
___ $25 - 5K stroller roll (adult) + $10 per child
Race day registration:
___ $25 - 1 mile walk/run/stroller roll
___ $30 - 5K (children & adults)
___ $30 - 5K stroller roll (adult) + $15 per child
T-shirt size (circle one):
Child: SM MED LG Adult: SM MED LG XLG XXL (add $2 for XXL)
*Pre-registration guarantees t-shirt
Please print neatly & fill out completely. Entries without age & gender will not be eligible for age group awards.
Name: _________________________________ Gender: M ___ F ___ Age on race date: ___
Address: _____________________________ City: _____________ State: ____ Zip: _____________
Phone: ________________ E-mail: ____________________ Date of birth (mm/dd/year): ___ /___ /____
Waiver must be read and signed before mailing:
"In consideration of this entry being accepted, I hereby for myself, heirs, executors, administrators, waive and release any and all rights and claims for
damages I may have against Loop the Lake, race officials, and all sponsors, of all claims or liabilities of any kind arising out of my participation in this
event or while traveling to and from. I allow any photographs or materials from this event to be used to publicize this or future Loop the Lake events."
Total amount paid: $_________
Cash ___
Check ___ Check # ________
Signature required: __________________ Date: __________ Parent’s signature if under 18: __________________