Obstacle Race Registration Form Register for Obstacle Walk/Run Name* First Last Email* Date of Birth Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Person to notify in case of emergency*Phone number of emergency contact*Company NameAre you registering as part of a team?*If you are running as a team please tell us your team name.How many people are on your team?*I'm a walkerJust me--I'm running/walking alone2345678Family Team: 3 shirts includedPlease list the names of your team membersWhat is your estimated 5K pace?*22-26 minutes26.5-29 minutesOver 30 minutesWalkingMultiply 3.2 miles times your average minute mile.How did you hear about the Race?*AFACXLABbG ClassFriendList serveOtherWhat is your shirt size?--Sorry we can not guarantee race shirt orders placed after 8am on 4/22.* No Shirt-Pls. donate the money to AFAC Youth-Large X-Small - Ladies Small - Ladies Medium-Ladies Large-Ladies X-Large - Ladies Small-Mens Medium - Mens Large- Mens X-Large-Mens One shirt for each registrant. Family registration includes 3 shirts.Payment Options*1 person $42Family $150Team of 8 $300You will complete payment after submitting this form.Additional AFAC Donation (optional) Total $0.00 I agree to participate in the BbG Obstacle Race and agree with the following Disclosure & Release. I agree to participate in an obstacle race with Body by Ginny. I recognize that participating in the obstacle race is not without varying degrees of risk of injury including, but not limited to, musculoskeletal and/or cardio respiratory systems. I hereby certify that I know of no medical problems that would increase my risk of illness and/or injury as a result of my participation in the obstacle race with Body by Ginny. I acknowledge and agree that I understand and assume any and all risks and dangers relating to my participation in the BbG Obstacle Race. I hereby release, discharge, indemnify, hold harmless BodybyGinny from and against any and all injury, illness, harm, claims, demands, actions or damages of any kind or nature resulting from or in any way relating to my participation in the BbG Obstacle Race. ** I agree Arlington County Hold Harmless AgreementIn consideration of my being granted permission to participate in these activities and to use the facilities of the County and/or other activities and services provided by the Arlington County Department of Parks, Recreation, and Cultural Resources, its agents and employees, including food service, I, on behalf of myself, my executor, administrators, heirs, next of kin, and successors, hereby covenant to hold harmless and indemnify the County and all its officers, departments, agencies, agents and employees from any and all claims,(except for claims based on malicious conduct by County officers and employees), lessees, damages, injuries, fines, penalties and costs (including court costs and attorney's fees), charges, liabilities, or exposures, however caused, resulting from or arising out of or in any way connected to me or my family's participation in the program. I have read and understand this HOLD HARMLESS AGREEMENT and agree to its terms. ** I agree NameThis field is for validation purposes and should be left unchanged.