YMCA Spring Chicken 5K Race Date: Sat., May 2nd, 2015 Race Starts at 9:00 a.m. A Race to Benefit the YMCA’s Strong Kids Campaign 2015 5K Fun Run/Walk Registration CHIP TIMED! In-Person or by Mail or online: Family YMCA of Northwest Illinois 2998 W. Pearl City Rd., Freeport, IL 61032 www.freeportymca.org Name:______________________________________________ Race Safety Gender (Please Circle): Male Female D.O.B.__________________________________ Mailing Address: ________________________________ City:______________________State:_____ Zip: _______ Phone: ______________________ Bicycles, roller skates, rollerblades and all other wheeled vehicles (except wheelchairs and racing strollers) are prohibited from the race in order to ensure the safety of runners. We also consider the use of headphones in running events to be a safety hazard and caution you to be careful when using them during the race. Email:______________________________________________ Fees: • $20 postmarked by 5/1/2015 • Pre-Race Registration ends 5/1/15 at 9:00pm • Race Day Registration from 7am to 8:30 am for $25 T-Shirt Size (Check One): ____ Adult-S ____ Adult-M ____ Adult-L ____ Adult-XL ____ Adult-XXL (add $2) Total Cost: $____________ 5K Run ($20/$25) $____________ T-Shirt Cost (If XXL is Ordered) $____________ Tax Deductible Donation to YMCA $____________ TOTAL ENCLOSED Race Waiver I hereby acknowledge that running/walking a road race is a potentially hazardous activity, and that I am medically able and properly trained to enter and run/walk. I agree to abide by any decision of a race official relative to my ability to safely complete the run/walk. I assume all risks associated with running/walking in the race, including, but not limited to, falls, contact with other participants, the effects of the weather, high heat and/or humidity, low temperature, traffic and conditions of the road. In consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf or on behalf of my estate, hereby waive and release all sponsors, event producers, event volunteers, race directors and staff, and all states, cities, counties or localities from all claims or liabilities of any kind related to or arising out of my participating in the race even though the liability may arise out of personal negligence or carelessness. I also grant permission for the use of any photographs, motion pictures, recordings or any other record of my participation in this event for any legitimate purpose and understand I will not be compensated for the use of such. I understand that if the race is cancelled because of circumstances beyond the control of the race committee and sponsors, including, but not limited to, unsafe weather conditions or governmental ban, my entry fee will not be refunded. Signature of Runner or Walker: _____________________________________________________________________ Date:____________________________________ Signature of Guardian (if under 18 years of age): ____________________________________________________________________ Date:___________________________________