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1st Annual Walk/Run for Wellness 5k Walk/Run 10K Run & Fun Run

Saturday, May 17th, 2014 9:00am Lewis County General Hospital


Registration Fee: 5K or 10K: $25.00-includes t-shirt and water bottle Fun Run: Free-includes participation ribbon Awards: Medals for 1st, 2nd & 3rd players in each age/sex category Race Information: Registration Check-In begins at 8:00 am. All races begin and end in Employee Parking Lot 4 on the Hospital Campus. All participants must sign an acknowledgement of risk and accident waiver and release of liability prior to the race (waiver on back of this page). Contact Information: For additional information, please contact Julie Glenn at 376-5200 or JoAnne Rhubart at 376-5110.

Entry Form
Name: ____________________________________________Sex: _______Age: ________________
Age on race day

Address: __________________________________________________________________________ State/Zip: __________________________________________________________________________ Phone: _______________________________ Email: ________________________________________ Sex: (please check one) Age Groups (please check one)

Male

Female

Under 25 25 to 40 Over 40
T-Shirt Size: T-Shirt Size: T-Shirt Size: S S S M M M L L L XL XL XL XXL XXL XXL

Event (please check one) 5K Walk $__________________ 5K Run $__________________ 10K Run $ __________________ Fun Run $ __________________ Total Enclosed $__________________

Note: T-shirts can only be guaranteed for participants registered by May 8th.

Please make checks payable to: Lewis County Hospital Foundation and mail to: 7785 North State St., Lowville, NY 13367

Lewis County Public Health

ACKNOWLEDGEMENT OF RISK ACCIDENT WAIVER AND RELEASE OF LIABILITY I, ______________________________________ (Participant) acknowledge that I have voluntarily applied to participate in the ____________________________________ activities and acknowledge as follows: I fully understand and acknowledge that there are inherent risks and dangers in my participation the above activities and my participation in said activities and use of any equipment or materials related to such activities may result in my injury, illness or death and damage to or loss of my personal property. I understand other participants, accidents, forces of nature or other causes may cause these risk and dangers and hereby fully acknowledge and accept these risk and dangers. I am in good health and I am able to participate in any strenuous physical activity associated therewith. I herewith release, forever discharge and waive any right of recovery or subrogation against Lewis County Hospital Foundations activities, its officers, directors, employees and volunteers from any and all liability whatsoever for any illness or injury, including death or damage to or loss of my personal property that I may sustain while I am participating in this program. This shall be binding on my heirs, successors, assigns, administrators and executors and executors. Any claims or disputes arising out of my participation in the activity shall first be submitted to arbitration and/or be venued in the Supreme Court of the State of New York of the County of Lewis. I HAVE READ THE ABOVE OR I ACKNOWLEDGE, IF VERIFIED THAT I HAVE HAD THIS DOCUMENT READ TO ME AT MY REQUEST AND BY SIGNING IT I AGREE IT IS MY INTENTION TO PARTICIPATE IN THE INDICATED ACTIVITY AND I UNDERSTAND AN ACCEPT ALL THE RISKS INVOLVED. DATE: ____________________ LOCATION: ________________________________________________________________________ PARTICIPANTS FULL NAME (print)____________________________________________________ DATE OF BIRTH: __________________________________ ADDRESS: _________________________________________________________________________ PARTICIPANT SIGNATURE: _________________________ _________________________________
PARENT OF PARTICIPANTS UNDER AGE 18 SIGNATURE

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