2 ND A nnual K omen S pringfield R ace F or T he C ure • F riday E vening , M ay 15, 2015 • R egister
One Person Per Entry Form Contact Information
Copies Are Acceptable
LAST NAME
FIRST NAME
online at komenmemorial . org
EVENT
& ENTRY FEE Adult Walker
By
After Race
May26
3 Apr.
May 26
3 Day
Apr.
Day
1 Mile
5K $30 $35 $40
Adult 5K Timed Runner
ADDRESS/STREET
$33
$38$43
Kids for the Cure (12 & Under)
®
E-MAIL ADDRESS
Child Walker
CITY
Child 5K Timed Runner
$23 $28 $33
Spirit Walker - (From Home or Sideline)
STATE
ZIP
1 Mile
5K $20$25 $30
Non-Walk/Runner
DATE OF BIRTH
PHONE
AGE
FEMALE
$30 $35 $40
A. $___________
Enter Your Entry Fee Here:
MALE
OPTIONAL ITEMS
In the Pink - Jewelry Gift Team Name If Any (Team Must Be Formed Online In Advance.)
Suzy’s Garden Tulip
Available at Packet Pickup Only Please Mail My Packet
Available thru May 3rd Only!
Adult T-Shirt Size
SMALL
MEDIUM
LARGE
XLARGE
2XLARGE
Kids For The Cure™ T-Shirt Size
3XLARGE
XS/2-4
S/6-8
M/10-12
L/14-16
Mail Form & Fees To:
Breast Cancer Survivors
Yes, I am a breast cancer survivor. Please
send me a complimentary pin, pink cap &
t-shirt (included in registration fee).
®
$70 $
$20$
$ 5 $
B. $__________
Total Optional Items
TAX DEDUCTIBLE DONATION
Please Accept My Donation
Susan G. Komen Memorial
Attn: Springfield Race
4700 N. University St., Suite 92
Peoria, IL 61614-5849
C. $__________
TOTAL AMOUNT A+B+C = $_________
FOR OFFICE USE ONLY!
Cash
Credit
Check
By:
PLEASE READ & SIGN BELOW PHOTOGRAPHIC AND RESULTS RELEASE and WAIVER AND RELEASE OF CLAIMS
I AGREE THAT ANY AND ALL REPRESENTATIONS MADE AND RELEASES, WAIVERS,
COVENANTS, CONSENTS AND PERMISSIONS GIVEN BY ME HEREUNDER ARE GIVEN ON
BEHALF OF ME AND ANY AND ALL OF MY MINOR CHILDREN OR PERSONS OVER WHOM
I HAVE GUARDIANSHIP PARTICIPATING IN OR ATTENDING THE EVENT.
I give my consent and permission to The Susan G. Komen Breast Cancer Foundation, Inc.
d/b/a Susan G. Komen (“Komen”), its affiliates and races, their sponsors and corporate
sponsors, their successors, licensees, and assigns the irrevocable right to use, for any purpose
whatsoever and without compensation, (i) any photographs, videotapes, audiotapes, or
other recordings of me that are made during the course of this event (the “Event”); and
(ii) the results of my participation in this Event (e.g., race time, name, participant number).
I understand that (i) my consent to these provisions is given in consideration for being permitted
to participate in this Event; (ii) I may be removed from this competition if I do not follow all the
rules of this Event; and (iii) I am a voluntary participant in this Event. I am in good physical
condition and am solely responsible for my personal health, safety and personal property.
I know that this Event is a potentially hazardous activity and I hereby voluntarily assume full and complete responsibility
for, and the risk of, any injury or accident THAT may occur during my participation in this Event (INCLUDING, BUT
NOT LIMITED TO, MY FUNDRAISING ACTIVITIES associated with the event) or while ON THE EVENT PREMISES
(COLLECTIVELY, “MY PARTICIPATION”). TO THE FULLEST EXTENT OF THE LAW, I, FOR MYSELF, MY NEXT OF KIN,
MY HEIRS, ADMINISTRATORS, AND EXECUTORS (COLLECTIVELY, “RELEASORS”), HEREBY RELEASE AND HOLD
HARMLESS AND COVENANT NOT TO FILE SUIT AGAINST (I) KOMEN, THE PEORIA MEMORIAL AFFILIATE OF THE
SUSAN G. KOMEN BREAST CANCER FOUNDATION, INC. D/B/A MEMORIAL AFFILIATE OF SUSAN G. KOMEN FOR
THE CURE AND ALL OTHER KOMEN AFFILIATES AND THEIR RESPECTIVE DIRECTORS, OFFICERS, VOLUNTEERS,
AGENTS AND EMPLOYEES; (II) ANY EVENT SPONSORS; AND (III) ALL OTHER PERSONS OR ENTITIES ASSOCIATED
WITH THIS EVENT (COLLECTIVELY, THE “RELEASEES”) FOR ANY INJURY OR DAMAGES I MIGHT SUFFER IN
CONNECTION WITH MY PARTICIPATION. THIS RELEASE APPLIES TO ANY AND ALL LOSS, LIABILITY, OR CLAIMS I
OR MY RELEASORS MAY HAVE ARISING OUT OF MY PARTICIPATION, INCLUDING BUT NOT LIMITED TO, PERSONAL
INJURY OR DAMAGE SUFFERED BY ME OR OTHERS, WHETHER SUCH LOSSES, LIABILITIES, OR CLAIMS BE
CAUSED BY FALLS, CONTACT WITH AND/OR THE ACTIONS OF OTHER PARTICIPANTS, CONTACT WITH FIXED OR
NON-FIXED OBJECTS, CONTACT WITH ANIMALS, CONDITIONS OF THE EVENT PREMISES, NEGLIGENCE OF THE
RELEASEES, RISKS NOT KNOWN TO ME OR NOT REASONABLY FORESEEABLE AT THIS TIME, OR OTHERWISE.
I UNDERSTAND THAT I AM SOLELY RESPONSIBLE AND LIABLE FOR ALL ASPECTS OF
MY FUNDRAISING ACTIVITIES ASSOCIATED WITH MY PARTICIPATION, INCLUDING, BUT
NOT LIMITED TO, THE SAFE AND LAWFUL CONDUCT OF ANY FUNDRAISING ACTIVITIES.
This Photographic and Results Release and Waiver and Release of Claims (collectively, the
“Release”) shall be construed under the laws of the state in which the Event is held. In the event
any provision of this Release is deemed unenforceable by law, (i) Komen shall have the right
to modify such provision to the extent necessary to be deemed enforceable; and (ii) all other
provisions of this Release shall remain in full force and effect.
I understand that I have given up substantial rights by signing this Release, and have signed
it freely and voluntarily without any inducement, assurance or guarantee being made to me
and intend my signature to be a complete and unconditional release of liability to the greatest
extent allowed by law.
X
Print Participant’s Name
Participant’s Signature (or Parent/Guardian, if under 18)
______/_____/2015
IGNITE THE PASSION
Schedule of Activities
FUNDRAISING
How does a 5K race make a huge
impact on the movement to end
breast cancer forever?
Through the fundraising efforts of every participant.
You don’t need to be a fundraising expert to be
successful—you just need the desire to stand up to
breast cancer and make a difference. This year we’re
counting on you to aim high! Remember: Every dollar
makes an impact.
TEAM REGISTRATION
Forming a Team has loads of
benefits! First and foremost, it Is FUN!
What better way to spend time with
your family, friends, colleagues or
schoolmates than to form a Race Team,
to support the Komen® vision of a world
without breast cancer and to motivate
and inspire one-another? There is no
extra cost to form or join a team.
Let your children show their pride in the
fight against breast cancer. This is an
exciting opportunity to encourage
children ages 12 and under to participate
in a constructive, fun way. Participants
receive a specially designed Kids for the
Cure® T-shirt and are able to enjoy the
Kids’ Corner on Race Day. T-shirts are
distributed on a first come, first served
basis. Sizes are not guaranteed.
FUNDRAISING
REWARDS
Earn great prizes! Start earning
rewards when you reach $250 in
donations. For more information,
visit komenmemorial.org.
•
•
•
•
5:00 p.m. • Activities Begin
• On-site Registration
• Live Band
• Kids Corner
5:45 p.m. • Opening Ceremony
6:15 p.m.
• Survivors Convene in Survivor
Village Area for Procession (Line up by years of survivorship)
6:30 p.m. • Survivor Group Photo
with Mr. Lincoln
6:35 p.m. • Aerobic Warmup
7:00 p.m. • Competitive/Timed Run
7:02 p.m. • 5K Family Run/Walk
7:10 p.m. • One Mile Family Walk
8:30 p.m. • Awards Ceremony
8:45 p.m. • Pink Fireworks over State Capitol
2
nd
Annual
Komen Springfield®
Race for the Cure
Friday Night
IGNITE
THE PASSION
May 15, 2015
®
State Capitol
Springfield, IL
5k Run/Walk • 1 Mile Family Walk
KIDS FOR THE CURE®
Team Formation is a great way to celebrate breast
cancer survivors or honor the lives of lost loved ones.
Teams embody the Komen® philosophy of empowering
people! Any group is eligible to be a Team: businesses,
families, schools, clubs, scout troops, military, churches,
friends . . . you get the idea. A Team must include 10 or
more participants. Teams must register online at
REWARDS & INCENTIVES
GENERAL INFORMATION
Largest Team Recognition
Top fundraising team name on next years Race t-shirts
Individuals who raise $1500-One Race Day VIP area ticket
Individual $5,000 fundraisers win an American Airlines
certificate to be redeemed for 25,000
AAdvantage miles. Miles may be redeemed for
flights, upgrades, hotels and shopping.
SPIRIT WALKER
Going to be out of town on Race Day?
Working Late? Can’t physically attend? Be
here in spirit. Your $30 helps the fight
against breast cancer. PLUS, you receive a
race T-shirt.
IN THE PINK
Be truly “In The Pink” on Race Day
by supporting the fight against breast
cancer in a special way. Check the “In
the Pink” box and donate an additional
$70. and receive a classic pink cultured
freshwater stretch pearl bracelet with a
pink ribbon charm.
Provided By:
Giving
StrengthSUSAN
&G. KOMEN MEMORIAL
PEORIA RACE FOR THE CURE
Hope to
SATURDAY, MAY 10, 2014
Survivors.
Register at komenmemorial.org
®
METRO CENTRE • PEORIA, IL
5K RUN/WALK • 1 MILE FAMILY WALK
Honorary Race Chairs
JANE ARBUTHNOT, M.D. • VICTORIA RINGER
LOCALLY
PRESENTED BY:
Register Now!
MEMORIAL
komenmemorial.org
Journal Star
Always Worth Looking Into
RLI
SPRINGFIELD
Susan G. Komen The Running Ribbon is a registered trademark of Susan G. Komen.
DIFFERENT WORKS
January 15, 2015
Susan G Komen for the Cure
Ms. Gayle Young
4700 N. University
Suite 92
Peoria, IL 61614
NATIONAL SPONSORS
Name of Event: Susan G Komen for the Cure- Circle of Promise
Arrival Date: Saturday, April 25, 2015
Dear Ms. Young,
This letter is to confirm your reservation with the Par-A-Dice Hotel Casino.
FUNCTION SPACE
The Par-A-Dice Hotel Casino requires a firm and detailed schedule to insure that detailed function/ banquet
specifications can be drafted and returned within sufficient time for mutual review and approval. The following
space has been blocked based upon your requirements.
FUNCTION AGENDA
Date
4/25/2015
4/25/2015
Start Time
8:00 AM
9:30 AM
End Time
9:30 AM
12:00 PM
Function
Setup
Breakfast
Buffet
Room
Grand Ballroom
Grand Ballroom
Setup
Rounds of 10
Rounds of 10
Agr
500
Room Rental
.00
.00
The room designated for your event was assigned based on estimated attendance. If your final number falls below
this, the hotel reserves the right to transfer your event to another function room to better accommodate all
meetings and banquet functions. If additional function space or changes are required revised rates may be
warranted. Significant reductions in meal counts may result in a penalty based on the current room rental rate.
Any room set changes made on site will be charged at $50.00 per room. Exhibitors will be required to pay a $35.00
exhibit fee per 6’ or 8’ draped table.
FOOD AND BEVERAGE
A guaranteed number of guests are required five (5) business days prior to function or we will bill and prepare for
the estimated number of attendees. You will be charged for the guarantee number of attendees or the exact
number serviced whichever is greater. The hotel will prepare for up to 5% over the guarantee for the meal
function.