Lezlie Blasius Memorial 5 Registration Form

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