Tri-Race Registration Form
Kick Up The Dust (April 3) - Ballon Chase Bike Ride or Run/Walk (July 3) - 12K's for the Holidays (Nov. 20). Registration fee $100 (includes all 3 races) offer good through April 1st only! (Must register BEFORE March 20, 2021 to make sure you receive a Kick Up The Dust T-shirt) Thank you for supporting Good Samaritan Center in this way.
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Email *
Full Name *
Date of Birth *
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Sex *
Phone Number *
Address *
Kick Up The Dust Distance *
Balloon Chase Distance *
12K's for the Holidays Distance *
Shirt Size Preference *
For 12K's for the Holidays, you receive the choice of a cotton or technical style T-shirt! Which would you prefer? *
Waiver: In consideration of acceptance of this entry, I waive any and all claims for myself and my heirs against The Good Samaritan Center, MS Race Timing, Miss. College, Canton Parks & Recreation, Canton Convention & Visitors Bureau, Mid-Mississippi Balloon Association, Fleet Feet Sports, Fondren Renaissance Foundation, Event Sponsors, and Event Planners for injury or illness which may directly or indirectly result from participation in this event. I further state that I am in proper condition to participate in this event. I also give my permission for the free use of my and/or my minor child’s picture in any broadcast, photographs and other accounts of this event. *
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Waiver: In consideration of acceptance of this entry, I waive any and all claims for myself and my heirs against The Good Samaritan Center, MS Race Timing, Miss. College, Canton Parks & Recreation, Canton Convention & Visitors Bureau, Mid-Mississippi Balloon Association, Fleet Feet Sports, Fondren Renaissance Foundation, Event Sponsors, and Event Planners for injury or illness which may directly or indirectly result from participation in this event. I further state that I am in proper condition to participate in this event. I also give my permission for the free use of my and/or my minor child’s picture in any broadcast, photographs and other accounts of this event. *
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Participant/Guardian (if under 18): Please initial here to "sign" the above waiver. *
A copy of your responses will be emailed to the address you provided.
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