Pay By Check - Indian Run Registration Form - Event Date October 7, 2023

Indian Run

Hosted by Historic Pocahontas, Inc.
38th Annual Indian Run

OCTOBER 7, 2023

  LOCATION: Pocahontas, VA (124 E Water Street)

ONSITE REGISTRATION: 8:00 AM to 8:45 AM

RACE START: 9:00 AM (youth events at 10:30)

If you experience any issues completing and submitting this form, please email us at HPIIndianRun@gmail.com

PRE-REGISTRATION FEE: (ends September 15)

$20 : 8K Run/5K Run/5K Walk

$10 : Youth Events

(Papoose 2- 5 yrs & Brave Run 6-9 yrs)

$5 Each additional sibling

AFTER SEPTEMBER 15:

$25 : 8K Run/5K Run/5K Walk

$15 : Youth Events

(Papoose 2- 5 yrs & Brave Run 6-9 yrs)

$5 Each additional sibling

NOTE: For guaranteed T-shirt register by September 15. All others 1st come 1st serve.

Contact info:

Phone 276-945-2101

Email HPIIndianRun@gmail.com

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Participant Details - All 8k and 5k participants must register separately
IF REGISTERING FOR YOUTH EVENTS, PLEASE COMPLETE CONTACT INFORMATION FOR PARENT/LEGAL GUARDIAN THEN FILL IN YOUTH NAME, AGE, AND T-SHIRT SIZE IN APPROPRIATE SECTION BELOW.
Full Name*

First NameLast Name
Age as of October 1, 2023*
Date of Birth

MonthDayYear
Date
Please Select*
Email
example@example.com
Phone Number (We will only contact you if there are questions regarding the registration)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

First NameLast Name
Emergency Person Phone Number*

Area CodePhone Number
Relationship to Emergency Contact Person
IF REGISTERING FOR YOUTH EVENTS, FILL IN PARTICIPATE NAME AND AGE BELOW:
Youth Name Youth Age
Youth Name Youth Age
Youth Name Youth Age
Youth Name Youth Age
Request T-shirt Size (not guaranteed after September 15)

Adult SAdult MAdult LAdult XLAdult XXLYouth SYouth MYouth L
If registering more than one youth, select t-shirt size for 2nd youth below (not guaranteed after September 15)

Youth SYouth MYouth L
If registering more than one youth, select t-shirt size for 3rd youth below (not guaranteed after September 15)

Youth SYouth MYouth L
Registration Payments
**To pay by check, make payable to Historic Pocahontas, Inc.

Please be sure to include the name of participant(s) with check and mail to:

Historic Pocahontas, Inc.

ATTENTION: Indian Run

PO Box 398

Pocahontas VA 24635
My Products
prevnext( X )
8K run $25.00

5K run$25.00

5K walk$25.00

Youth - Papoose Run 2 -5 yrs $15.00

Youth - Brave Run 6 - 9 yrs$15.00

Additional Sibling - Papoose Run 2 - 5 yrs$5.00
select quantity below

Quantity

Additional Sibling - Brave Run 6 - 9 yrs$5.00
select quantity below

Quantity

Total $0.00
Waiver & Release
Type a question*

I confirm that I am in good shape, health, and condition.I don't have any medical condition or medical history that will affect my participation in this event.I will follow the rule and regulations of the road race event.I acknowledge that this road race requires physical activity and there are possible risks and danger.I release the road race event organizers for any responsibility in case of an accident, illness, or injury.I allow my photo to be taken during the event and used for event advertising and marketing.I confirm that all information in this registration form is accurate and true.
Date Signed*

MonthDayYear
Date
Signature*
Should be Empty:

Indian Run

Participant Details - All 8k and 5k participants must register separately

Registration Payments

Waiver & Release