4 th Annual Bern Independence Day
5K Run/Walk
Saturday July 4, 2015
Bern City Park
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7:00 AM Registration/packet pick up
8:00 AM Start Time
$20 Entry Fee before June 17 th , $25 Entry fee after June 17 th
Pre-registration by June 17 th Guarantees a race t-shirt.
T-shirts cannot be guaranteed after that date.
Mail completed entry form and check payable to:
Bern Independence Day 5K
C/0 Ronda Haverkamp
3021 L4 Road
Bern, KS 66408
(Registration forms may also be dropped off at the State Bank of Bern)
Entry Form
Name: ____________________________________ P hone: ________________ Address: _________________ City: _____________State: _____ zip: ________ Email: __________________________Sex: ____ M ____ F Age on race Day: ___ Unisex t-shirt size (Pick one): S M L XL 2XL Youth S Youth M Youth L
I am a voluntary participant in this event and in good physical condition. I understand that participation in this event involves
potentially severe injuries. Permanent paralysis or death can occur in any activity involving physical activity and motion. I hereby
assume full responsibility for any injury or accident which may occur during my participation in this event or while on the premises of
this event and I hereby release and hold harmless the city of Bern, its elected officials, employees, the event planning committee,
sponsors and any affiliated individuals and all other persons or entities associated with this event from any claims I may have arising
out of my participation in this event, including personal injury or damages suffered by me or others whether same be caused by
negligence of the organization or any affiliated individuals including any of the said parties agents or employees or otherwise. I also
know that some protection is provided but there will be traffic on the course. I assume any and all risk of running in traffic. I give my
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full permission to the Bern 4 of July Event to use any photos, videos or other recordings of me that are made during the course
event.
Signature: ___________________________________ Date: ______________ Parent/Guardian: ___________________________________ ( if under age 18)