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Last Name
Address
City
State
Zip
Phone
Email
Gender:
Male
Date of Birth
Age
Female
T-Shirt Size:
Have you run this race before?
Small
Yes
Medium
No
Large
Sponsor’s Name
Amount
1. ___________________
$ ____________
2. ___________________
$ ____________
3. ___________________
$ ____________
4. ___________________
$ ____________
5. ___________________
$ ____________
6. ___________________
$ ____________
7. ___________________
$ ____________
8. ___________________
$ ____________
9. ___________________
$ ____________
10. __________________
$ ____________
11. __________________
$ ____________
12. __________________
$ ____________
Is this a new address?
X-Large
Yes
2X-Large
No
Runner #_________ Amount: $ ___________
Waiver of Liability (Must be signed):
I understand that HeartShare Human Services of New York and
all other organizations or persons connected with this event
are not responsible for any injuries which I may suffer while
taking part in this event or as a result thereof. I hereby waive
any claim of damages to my person and/or personal property.
All sponsor donations are fully tax deductible.
Make checks or money orders payable to
HeartShare Human Services
Runner: __________________________________
We strongly encourage you to ask family, friends
and co-workers to sponsor you. If needed, you
may copy this sheet for additional sponsors.
_________________________________________
Parent/Guardian (if runner is under 18 years old)
35TH ANNIVERSARY
Buckley’s - Kennedy’s
5K Charity Run
SUNDAY, MAY 17, 2015
10:00 AM • RAIN OR SHINE
Address Service Requested
First Name
2015 Buckley’s - Kennedy’s Run
Registration Form
PLEASE PRINT CLEARLY
35th Anniversary Buckley’s - Kennedy’s Run
HeartShare Human Services of NY
12 MetroTech Center, 29th Floor
Brooklyn, New York 11201
2015 Buckley’s - Kennedy’s Run
Registration Form
PLEASE PRINT CLEARLY
In Loving Memory Of
Thomas Carroll
All Proceeds Benefit
35 ANNIVERSARY
Buckley’s - Kennedy’s 5K Charity Run
TH
SUNDAY, MAY 17, 2015 • 10:00 AM • RAIN OR SHINE
WAYS TO REGISTER
Register Online
REGISTRATION FEES
$20.00 Registration for adults 19 and older
$25.00 Registration on day of the run
$10.00 Registration for youth 18 and under
Visit www.heartshare.org/run
(Online registration closes May 15 at 12:00 pm)
Register By Mail
NON-RUNNER FEES
Mail your completed application
(on reverse side) and payment by May 8 to:
35th Anniversary Buckley’s - Kennedy’s Run
HeartShare Human Services of NY
12 MetroTech Center, 29th Floor
Brooklyn, New York 11201
For runners registering by mail, numbers and T-shirts may be
picked up during on-site registration at Buckley’s Restaurant
from May 14 to May 16, 3:00 pm - 8:00 pm.
RUNNER INFORMATION
Runners arrive at 9:30 am in front of the Army
Reserve Center, located on Rockaway Point
Blvd/State Road between Barret Road and
Hero Road in Breezy Point, NY. For GPS, use
the address of St. Genevieve’s Church: 6 Beach
178th Street, Breezy Point, NY 11697 located
across the street from the Reserve Center.
Runners clothing must be placed in plastic bags
prior to race time. Immediately following the
race, runners may pick up their clothes near the
runners entrance to the Family Fun Day Picnic.
Strollers are allowed behind the field of runners.
PARKING & SHUTTLE BUS INFORMATION
Runners and picnic guests may park at the
Army Reserve Center. Shuttle buses will run
between the parking lot and the Breezy Point
baseball field from 8:30 am until 4:00 pm.
You will not be able to park in Breezy Point.
TROPHY INFORMATION
Trophies are presented to the overall fastest
male and female participants and to the top
three males and females in each of the
following age groups:
• 12 and under
• 13 - 19
• 20 - 29
• 30 - 39
• 40 - 49
• 50 - 59
• 60 - 69
• 70+
FAMILY FUN DAY PICNIC
AT BREEZY POINT BALL FIELD
11:00 AM - 3:00 PM
THE PICNIC IS OPEN TO THE GENERAL PUBLIC
AND FEATURES:
• Live Music provided by Head Over Heels
• Entertainment by DJ Suds
• Games and Rides
• Food and Beverages
You must be 21 or older to be served beer.
The picnic is FREE for all registered runners.
$10.00 Food and Beverages
$15.00 Food, Beverages and T-Shirt
Children 12 and under are FREE
Methods of payment include VISA, MasterCard,
American Express or Discover Card, or by check or
money order payable to:
HeartShare Human Services of New York
Register In Person
The registration fee is waived for any adult runner
collecting $50.00 or more or for any youth runner
collecting $25.00 or more in sponsorships!
Thursday, May 14
Buckley’s Restaurant - 3:00 pm - 8:00 pm
Kennedy’s Restaurant - 4:00 pm - 7:00 pm
18 AND UNDER RUNNER WITH THE
MOST SPONSORSHIP DOLLARS WINS
iPad Mini (16GB)
Friday, May 15
Buckley’s Restaurant - 3:00 pm - 8:00 pm
Kennedy’s Restaurant - 4:00 pm - 7:00 pm
FOR MORE INFORMATION VISIT
www.heartshare.org/run
www.buckleyscaterers.com
Saturday, May 16
Buckley’s Restaurant - 10:00 am to 8:00 pm
2 pm REGISTRATION PARTY at Buckley’s
Music - Giveaways – Food - Beer Specials
Kennedy’s Restaurant - 1:00 pm to 5:00 pm
Sunday, May 17
Near Start Line - 7:00 am to 9:00 am
Buckley’s Restaurant
2926 Avenue S, Brooklyn, NY 11229
Kennedy’s Restaurant
406 Bayside, Rockaway Point, NY 11697
Run Hotline
718.422.3347/3283
Day of Race
347.853.3722
Method of Payment:
VisaDiscover
MasterCardCheck/Money Order
American Express
Cash - On-site
Registration ONLY!
Name as it appears on card
Credit Card #
Signature
Exp. date