Categories:
11 and under
12-17 years of
18-29 years of
30-39 years of
40-49 years of
50-59 years of
60-69 years of
70 and up
age
age
age
age
age
age
May 16th 2nd Annual Rock N Run
for Diabetes 5k/10k
Cumberland Presbyterian Church start
and finish at Farmers Park for the party!
4:30 pm check-in
The awards ceremony and prize giveaway will be held following return of all runners. Awards will be given to the top
three in each age group - must be present to receive award. 18 and under overall, 18 and up Male and Female.
21 and participants over will receive a ticket to the Rock the Cure event with Sequel Dose starting at 7:30 pm
There is a runners area at the event for awards with light snacks and beverages upon your return to
Farmers Park. This is for all ages until awards are complete. Over 21 can stay for Sequel Dose.
Each participant must fill out a form—Please note this is a run only
5k_____ 10k______
Name:_________________________________________________________________________
Address:_________________________________City: _________________State: _____ Zip:_________
E-mail ______________________________________________Phone____________________
Shirt size (circle one): Adult: S M L XL 2XL 3XL Youth: S M L Runner Category Info: Age as 5/16/15 ____
Female Male
For safety reasons: no headphones, skates, skateboards, bicycles or animals will be permitted
Please note: NO refund will be issued for weather or any other reason.
I recognize and acknowledge that there are certain risks of physical injury in this event. I and my insurer, hereby release, waive, relinquish, and discharge JDRF International, Ozarks, and Metro St. Louis. and any other sponsor and any and all directors, officers, employees, agents, and/or volunteers from any and all claims, demands, action, or causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by myself as a result of
my participation in the event, whether caused by negligence (including, but not limited to, negligence by any person acting on behalf of JDRF International, Ozarks,
and Metro St. Louis., negligent training, or negligent supervision), weather conditions, or otherwise. I further acknowledge that I understand that this is a full release
and that I have voluntarily waived my rights and those of my insurer. I verify that I am physically fit and have sufficiently trained for the completion of this event. I have
read the entry information provided and certify my compliance by my signature below. JDRF has permission to use pictures, slides, and/or audio-video tapes of me
during this event for publicity and public relations purposes.
Signature: ______________________________________________________ Date: ________________
Parent/Guardian Signature: __________________________________________Date: ________________
(for runners younger than 18)
Credit Card Payment info: MC V D AX ___________________________________ Exp________ Total_______
Fees & Payment
5k Registrant $30 ___
Day of race: $35. Unisex t-shirt. $6 upgrade to Tech ___
10k Registrant $35 ___ Day of Race: $40. Unisex t-shirt. $6 upgrade to Tech ___
MUST USE THIS FORM ONLY. Copies not allowed and discount for Past runners only.
Mail to JDRF, 2200 E. Sunshine, Suite 122, Spfd, MO 65804
Cumberland Presbyterian, 4216 S Charleston Ave, Springfield, MO 65804
For questions, call Jennifer Cotner-Jones at (417) 559-9122 or [email protected]
For a guaranteed shirt and size, you MUST be registered by May 1st. After this date shirts MAY be available onsite
and sizes are NOT guaranteed.