Begin at Recreation Center— Wisconsin St. to Mill Pond path cross over Grand continue on Rubicon River Trail path to Willowbrook Park S to WB Place/Clinic Parking Lot Run over footbridge to FINISH! Hartford, WI 53027 L on Rubicon River Trail through West Side park 125 N. Rural St. L on Wilson Ave. L on Union St. R on 6th St. L on Highland L on Main St. R on High St. R on State St. L on Grant St. Hartford Parks & Recreation Center Continue through the park (Rubicon River Trail) Hartford Recreation Department Kissel vehicles were manufactured in 125 N. Rural St. Hartford, WI 53027 Hartford, WI from 1906-1930. 262.670.3730 REGISTRATION INFORMATION First Name: ________________________________________ Last Name: ________________________________________ DOB:_____/_____/_____ KISSEL KAR 5K RUN/WALK Saturday, August 1st 2015 Hartford Recreation Center 8:00 AM - check in / packet pick up Female_____ Male_____ Address:__________________________________________ City:_______________________ST_______Zip__________ Circle T-Shirt (adult sizes) S M L XL XXL Email address:______________________________________ Race starts @ 8:30 AM Phone H)___________ - ___________ - ___________ First and second place medals for male & female in each age group. Phone C)___________ - ___________ - ___________ T-shirts are guaranteed for all pre-registered participants (by July 16th, NOON) Only a limited number of extra shirts will be ordered & given out first come/first serve on race day. 14-17 18-23 24-29 Sign______________________________________________Date______ 30-39 40-49 50-59 60+ $18.00 - 3 or more from same family before July 16th @ NOON. Hartford Recreation Center and Schauer Arts & Activities Center after the race! Fun actives for all ages including swimming, bouncy house, scavenger hunt & yummy food from Mickey’s & ice cream from Scoop DeVille! MEDICAL EMERGENCY RELEASE WAIVER FOR MINORS: In the event of a medical emergency, I authorize the Parks & Recreation Department staff to obtain medical treatment for my son/daughter or minor for which I am guardian. MEDICAL INFORMATION: If there are any medical conditions/allergies/ disabilities the instructor/program supervisor should be aware of, the participant or parent of the participant should discuss this with the instructor./program supervisor the first time the program meets. Registration Fees: $20.00 before July 16th @ NOON Come celebrate the 15th Anniversary of the ing release. Parents or guardians must sign for minors. I, the undersigned do hereby agree, or agree for the above named registrant for whom I am the parent or guardian, to participate in the activity indicated am aware of and understand that there may be risks and hazards inherent with participants in this activity. I affirm that I, or the minor registered for this activity, am doing so as a voluntary participant. In consideration of my participation or participation of the minor I do hereby agree to release, waive, absolve, indemnity on behalf of myself or minor, my/his/her/family, my/his/her heirs and my/his/her assigns the City of Hartford, its employees, officers, agents and sponsors from liability for injury, death or loss suffered by me or the minor in any and all present and future claims, liabilities, damages or right of action directly or indirectly resulting out of participation in the activity, using the facilities, or engaging in any activities incidental thereto during the duration of the scheduled program, which result from the ordinary negligence for the City of Hartford, its employees, officers, agents and sponsors. The City of Hartford does not provide accident insurance to participants in recreational activities and I assume full responsibility for any and all injuries or damages which may occur to me while participating. PHOTO RELEASE: I agree to allow publication of any photos taken at any program, event, or facility of the City of Hartford Parks & Recreation Department. AGE GROUP (check one): 13 LIABILITY WAIVER: All participants are required to sign the follow- $30 after NOON on July 16th & race day (t-shirt NOT guaranteed on race day registrations) Checks payable to : City of Hartford (Parents must sign for minors) If faxing, be sure to include information below. FAX # 262-673-8303 Credit Card Number: _____________________________ Expiration Date:_____/_____ V-Code:__________