Lezlie Blasius Memorial 5K Walk/Run Registration Form Complete this form and return to Kimball High School on or before 10/10/14. Thank You! First Name: ____________________________________________________________________ Last Name: _____________________________________________________________________ Gender: ________________________________________________________________________ Email: __________________________________________________________________________ Phone Number: _______________________________________________________________ Address: _______________________________________________________________________ City: ____________________________ State: ________ $25 (Through October 10th) Sunday, October 12th, 2014 Zip: ________________ $30 (Day of Race) 2:00 pm Sign In 3:00 pm Race Wavier: I, for myself or as a parent or guardian, hereby assume all the risks and hazards incidental to the conduct of the activities. I understand that no insurance coverage is provided by the race coordinators and sponsors. I assume all risks associated with running in this race including but not limited to, falls, contact with other participants, the effect of the weather, including high heat and or humidity, the conditions of the road and traffic on the course, all such risks being known and appreciated by me. I further give permission for proper emergency care to be rendered to myself or child should I not be available or able to give such permission. All fees are nonrefundable. Race will take place rain or shine. In the event of extreme weather conditions or some other unforeseen act of God that may prohibit the race, all fees are nonrefundable. Having read this release and knowing these facts in consideration of your accepting my entry, I, for me and anyone entitled to act in my behalf waive and release this 5K, in the city of Kimball, South Dakota, and all claims and liabilities of any kind arising out of my participation in the race even though the liability may arise out of negligence or carelessness on the part of the persons referred to in this waiver. I also give permission for the free use of my name, and or pictures in broadcasts, telecasts, newspaper, posters, advertising, social media, etc. for any future event given by one of the organizations and entities associated with the event including but not limited to the Kimball FCCLA 5K Walk/Run, and any and all other sponsors of this event. _______________________________________________________________________________ Participant/Parent/Guardian ______/______/______ Date