Gaslight Festival - Jeffersontown Chamber of

Gaslight
Festival
Release of Responsibility
In consideration of your accepting my entry, I
intend to be legally bound, do hereby for myself,
my heirs, my executors and administrators,
waive and release forever any and all rights and
claims for damages I may accrue against all
persons and agencies including but not
restricted to, The City of Jeffersontown,
Jeffersontown Chamber of Commerce, Kosair
Charities, Headfirst Performance, the County of
Jefferson and any other city involved with
promoting the race as listed by name, their
successors, representatives, and assigns for any
and all injuries suffered by me while traveling to
and from and while participating in the Gaslight
5K Run/Walk in Jeffersontown, Kentucky and I
hereby represent that I have full knowledge of
the risks involved in this event and I am
physically fit and sufficiently trained to
participate in this event.
Signature of Entrant
______________
Date
________________________________________
Signature of Parent/Guardian if Entrant is under 18
______________
Date
For more information contact
The Chamber Jeffersontown at
502.267.1674 or visit
www.jtownchamber.com/gaslightfestival.aspx
The Chamber Jeffersontown
10434 Watterson Trail
Jeffersontown, KY 40299
_______________________________________
5K
Tuesday, September 15
Partnered with:
_____
2015 Gaslight Festival 5K Run | Walk
MI
Send check and this form to:
Gaslight Festival Run | Walk
10434 Watterson Trail
Jeffersontown, KY 40299
___________________________
Entry Fee: $20.00 if
postmarked by Sept. 4.
Late Entry Fee: $25.00
No refunds given.
First Name
YOU MUST SIGN WAIVER ON THE BACK OF THIS REGISTRATION
FORM. WE ENCOURAGE EARLY REGISTRATION TO AVOID LONG
LINES. Make checks payable to: Gaslight Festival 5K Run | Walk
Last Name
___________________________
______________
Phone Number
Zip Code
(_______)______________
________
______________________________________
State
Address
________________________________
ADULT
Circle T-shirt Size
KID
S
2015
M
Kosair Kid®
L
Noah & Gabriel Renner
XS
S
M
L
XL
2X
3X
For more information please contact:
The Chamber Jeffersontown
10434 Watterson Trail
Phone: (502) 267-1674
[email protected]
City
T-shirt size is not guaranteed to
late registrants.
___________________________
Participants will receive a Gaslight Festival
5K shirt.
Email
T-shirts:
Since 1923 Kosair Charities has had one primary
mission – helping children in need. Kosair Charities
knows that the quality of a child’s tomorrow depends
largely on the quality of health, medical treatment, &
support a child receives today. That’s why over the
years Kosair Charities has
given away millions of
dollars to serve thousands of
children and provide them
a second chance at life.
For more information
visit www.kosair.org or
call 502.637.7696.
Sex
Registration fee for all event day registrants.
Event day registration is from 5:00 PM - 6:30 PM.
____
Late Registration: $25.00
______
After that date & time you must register on the day
of the event.
0-14 15-19 20-24 25-29 30-34
35-39 40-44 45-49 50-54 55-59
60-64 65-69 70+
Wheelchair
Age on Race day
Registration will close on Friday,
September 4 at 4:30 PM.
Age Groups:
$ ________
Registration fee for all applications
received, or postmarked by September 4, 2015.
Prizes
 Cash prizes to the top male and female finishers
 Awards to the top 3 finishers in each age group
 All will be eligible for the Grand Prize Drawing
$25
Preregistration: $20.00
Packets can be picked up prior to race day on Monday,
September 14 from 10:00 AM - 5:00 PM at
The Chamber Jeffersontown.
ALL REMAINING PACKETS MUST BE PICKED UP ON
RACE DAY AT THE JEFFERSONTOWN PAVILION FROM
5:00 PM - 6:30 PM
$20
completed form to: The Chamber Jeffersontown
Attn: Gaslight 5K 10434 Watterson Trail
Jeffersontown, KY 40299
If you need to print additional forms visit:
www.jtownchamber.com/gaslightfestival.aspx
Online: Visit www.headfirstperformance.com
Packet Pickup
$15
Mail: Fill out the attached registration form & mail
$10
Register
Date of Birth: ____ /____ /
Month / Day / Year
$5
7:00 pm
Would you like to make a donation to Kosair Charities?
Circle amount for donation & include total amount (registration + donation) with payment.
$1
Tuesday, September 15
The race starts and finishes in front of Jeffersontown City Hall