April 25, 2015 EVENT LOCATION: Punderson State Park – 11755 Kinsman Rd., Newbury, OH 44065 USA Track & Field Certified Course SCHEDULE OF EVENTS: 8:00-8:30 am 8:30 am 9:00 am First Name Registration Warm Up Chip Timed 5k Run/1 Mile Fun Run Last Name Address Apt.# City State Zip Phone E-mail M Participants Waive In consideration for allowing me (my child) to compete in the 5K Race/1 mile Fun Run, I, the undersigned intending to be legally bound, waive and release, for (my child) myself, my heirs, executors and administrators, any and all rights and claims for property damage and personal injury, including death, which I (my child) representatives, successors and assignees, arising from my participating in this event. I verify I have full knowledge of the rigors of this race and the risk involved in participation, and I am (child is) physically fit and have (has) sufficiently trained to compete in this event. I (on behalf of my child) hereby grant permission to Geauga County Job & Family Services and its sponsors to use all information submitted in my application and my photograph, video tape, motion picture, recording and any other record of this event including pre-race and post-race publicity. Signature of participant Date (If a minor, please obtain signature of parent or guardian) Signature of guardian (If participant is a minor) Date F Age on event date Pre-Register with the minimum donation to receive a T-Shirt T-Shirt Size: S ___ M___ L___ XL___ 2XL(Add $2.00) ___ Child’s T-Shirt Size: S ___ M___ L___ Emergency Contact Name ______________________________ Phone Number______________________________ Please Register me for: Chip Timed 5K Race ____ 1 Mi. Fun Run ___ $20.00 Pre-Registration $10.00 Children 12 & Under Pre-Registration must be received by 4/8/15. All pre-registered entries include Goody Bag and T-shirt. $25.00 Day of Registration $15.00 Children 12 & Under Event Day Registration (please complete and bring with you) All event day registered entries include Goody Bag and T-shirt (if available) Enclosed is additional money raised $_______________ I cannot attend, but please accept my donation $___________ How did you find out about the race: ___________________________ Please make checks payable to: Geauga Children’s Alliance (In care of Geauga County Job & Family Services) Mail, or drop off this form to: 5K Race/ Fun Run – Attn: Rachael Tetlow 12480 Ravenwood Drive Chardon, OH 44024 Phone: (440)285-9141 Fax: (440) 286-6654 Geauga County Job & Family Services – 12480 Ravenwood Drive, Chardon, OH 44024 (440) 285-9141 • 1-800-209-7590 • COPELINE (440) 285-5665 • 1-888-285-5665 • www.geaugajfs.org