5KRUN/WALK&KIDSFUNRUN OCTOBER25,2014● 4:45PM NORWAYNEHIGHSCHOOL CRESTON,OHIO MISSION: To inspire courage and strength from within to conquer challenges in life, whether that challenge is ones first 5K, Stevens-Johnson Syndrome, or cancer. Amazing things can happen with FAITH, FAMILY, and FRIENDS by your side. Race Location: Norwayne High School, 350 South Main Street, Creston, OH 44217 REGISTER REGULAR STUDENT KIDS FUN Online Registration: https://runsignup.com/milesformadison BY: RATE for FEE for 5K RUN Registration/Packet Pickup: 3:35‐4:30 PM on race day 5K: (18&↓) (8&↓) Family Run Start: 4:45 PM ● 400 meters on Norwayne High School Track (par cipa on award for ages 8&↓) 9/30/2014 $20 $15 $10 5K Race Start: 5:30 PM ● http://connect.garmin.com/activity/247997335 ● FAST & 10/24/2014 $25 $20 $10 FLAT ● 1 water stop on course Awards Ceremony: 6:30 PM ● Refreshments will be provided RACE DAY $30 $30 $10 Awards: Awarded to the top 3 male/female, as well as top 3 male/female in each age group. (6 & under, 7‐8, 9‐10, 11‐12, 13‐14, 15‐19, 20‐24, 25‐29, 30‐34, 35‐39, 40‐44, 45‐49, 50‐54, 55‐59, 60‐64, 65‐69, 70+) Proceeds: All proceeds go directly to the Shannon Bitskay family ● https://www.facebook.com/smilesforshannon Entry includes a short sleeved shirt for all those Race Contact: Angela Deiotte ● [email protected] ● (330)464‐6380 who pre‐register before Complete the following information and return with check payable to: OCTOBER 18, 2014. Miles for Madison ● 171 North Main Street ● Creston, OH 44217 “LIKE” “LIKE” Miles for Madison on FACEBOOK: https://www.facebook.com/pages/Miles‐for‐Madison‐5k/519711884706459?ref_type=bookmark Costumes are encouraged on race day for all participants (kids and adults). Awards will be given to the scariest, cutest, silliest, and most original costumes following the Kids Fun Run. ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ PRINT: Last Name _____________________________________________________________ First: ______________________________________ Address: _____________________________________________ City: __________________________________State: _________ Zip: __________ Phone #: ( ) __________________________________ E‐Mail: _________________________________________________________________ √ Gender: □ Male □ Female Date Of Birth (MM/DD/YYYY): ______/______/____________ Age (day of race): ___________ √ if par cipa ng in 5K: □ √ T‐Shirt Size: Youth‐ YS □ YM □ YL □ ADULT‐ S □ M □ L □ XL □ XXL □ √ if participating in KIDS FUN RUN: □ √ T‐Shirt Size: Youth‐ YS □ YM □ YL □ AS □ AM □ Total Amount for 5K race entry or Kids Fun Run: $_______________ Donation for the Shannon Bitskay family $ ________________ GRAND TOTAL $_________________ Make checks payable to: Miles for Madison and mail to‐ Miles for Madison ● 171 North Main Street ● Creston, OH 44217 WAIVER OF LIABILITY: I know that participating in Miles for Madison is a potentially hazardous activity. I agree not to enter and participate unless I am medically able and properly trained. I agree to abide by any decision of an event official relative to my ability to safely complete the Event. I am voluntarily entering and assume all risks associated with participating in the Event, including, but not limited to, fall, contact with other participants, spectators or others, vehicular or other traffic, the effect of the weather, including heat and/or humidity, wind, cold temperature, wet or icy surfaces, falling tree branches or other overhead objects, traffic and other conditions of the course, all such risks being known and appreciated by me. Having read this Wavier and knowing these facts, and in consideration of your acceptance of this application, I, for myself and anyone entitled to act on my behalf, waive and release the Released Parties (defined below), from present and future claims and liabilities of any kind, known or unknown, arising out of my travel to or from or my participation in the Even or related activities, including personal injury of death, or property or economic damage, whether caused in whole or in part by the Released Parties or any other person or thing at the Event and even though such claim or liability may arise out of negligence or fault on the part of any of the Released Parties. PUBLICITY RELEASE: I grant permission to each of the Released Parties to use or authorize others to use any photographs, motion pictures, recordings, or any other record of my participation in the Event or related activities, including my name, for any legitimate purpose without remuneration. RELEASED PARTIES: This Waiver and Release is given to the Miles for Madison, Ohio Challenge Series, RS Racing Systems, the City of Creston and its agencies and departments, all sponsors and officials of the Event, and the officers, directors, employees, contractors, volunteers, agents, representatives, and successors of the foregoing. GUARDIAN’S PERMISSION AND RELEASE FOR MINOR: If I am signing this Waiver and Release on behalf of a minor, I understand and agree that my child’s participation in this Event is by my choice and, I agree that the Wavier and Release above applies equally to my child and me and any claims I, he or she may have. I also waive any derivative claims that relate to or arise out of my child’s participation in the Event. I also agree that the Publicity Release above applies to my child and me. RULES OF THE EVENT: I agree that attendance and/or participation in the Event is subject at all times to any and all rules and regulations of the Event. ALL ENTRIES ARE NON‐REFUNDABLE. Signature (of parent/guardian signature if you are under 18 years old): _______________________________________________ Date___________________