Gaslight Festival - Jeffersontown Chamber of
Transcription
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