REGISTRATION FORM
Lee County Sheriff’s Department Torch’s 5K
to benefit NW ILLINOIS SPECIAL OLYMPICS
May 9th, 2015 at Camp Reynoldswood, Dixon IL.
Race day registration opens- 7:30am
Race Time- 9am
Female
_________________________________________________________________________________ Male
First Name (Please print)
Last Name
Age
_____________________________________________________________________________________________
Address
_____________________________________________________________________________________________
City / State / Zip
Phone #
Email*- include for race results
EVENT:
Cash and checks for all registrations.
Individual Registration
Race day – all registration fees will be increased $5
5k- $25.00 (Race Day $30.00)
T-shirt size
Please circle
Name: __________________________________________ Age: ____ Gender: ___
Bib#: __________
YM
S M L XL 2XL
(Administrative use only)
I can’t walk/run, but will donate $_____________
Please checks payable to: Lee Co. Sheriff FOP 5K
Mail to: David Glessner; 306 S. Hennepin Avenue, Dixon, IL 61021
* Do not mail after April 24, 2015
RELEASE OF LIABILTY All participants must read and sign
Waiver: I know that running and/or walking this race is a potentially hazardous activity. I should not enter unless I am physically
able and properly trained to participate. I assume all risks associated with my voluntary participation in this event, including but not
limited to falls, contact with other participants, the effects of the weather (including precipitation or extreme temperatures), and all
conditions of the course, all such risks being known, understood and fully appreciated by me. Knowing these facts, and in
consideration of Lee County FOP Lodge 220 acceptance of my entry form, I, for myself, my assigns, my heirs and anyone else who
might claim on my behalf, hereby waive, release and discharge any and all claims of liability, whether foreseen or unforeseen, arising
out of or during the course of my participation in this event against Lee County FOP Lodge 220, its officers and directors, the Village
of Dixon, Camp Reynoldswood,, race sponsors, race officials, workers or volunteers, and any other cooperating and coordinating
groups and individuals associated with this event as well as their executors, administrators, representatives and assigns. I grant full
permission to Lee County FOP Lodge 220, the above mentioned sponsors, organizers, and/or any agents authorized by them to use my
likeness or image in any promotion for future race events without limitation or obligation. I further grant full permission to all media
organizations, their representatives and/or any agents authorized by them to use my name, likeness or image in the newspaper and in
any broadcast or telecast of this event without limitation or obligation.
____________________________________________________
Participant’s Signature
_____________________________________________________
Parent/Guardian (if Participant is under the age of 18 years)
_____________________________
Date
_____________________________
Date