2 Annual 5Kerry 5K Trail Run nd

presents
2nd Annual
5Kerry 5K Trail Run
Saturday, November 29, 2014
HOYT FARM NATURE PRESERVE
200 New Highway, Commack, NY
Start 11:30 am. Check in begins 9:30am
Race Timed by Long Island Race Timing
Prizes
T shirts
Register online with Active.com
or
mail form below postmarked by November 15
169 Commack Road
Suite H171
Commack, NY, 11725
Preregistration fee: $20
Race Day: $25
Teams of 10+: $15/person
Donations are tax free
Music by DJDK
Readings by
Psychic Medium
Nancy D’Erasmo
The Kerry Rose Foundation 5Kerry 5K Trail Run
$20 Preregistration Fee is enclosed
I am unable to attend but enclosed is a donation
Circle One: M/F
s/m/lg/xl Run/Walk
Name__________________________DOB:________
Address____________________________________
City______________________State____Zip_______
Phone______________E-mail___________________
I, the undersigned, intending to be legally bound , hereby, for myself, my, heirs, my assigns, executors, and administrators, waive and release any and all claims for damages I may have against the Kerry Rose Foundation, and all
other sponsors of the 5Kerry , the State of New York, the Town of Smithtown, and their employees, agents, representatives, successors and assigns, from any and all liabilities, claims, demands and causes of action whatsoever
arising directly or indirectly from my participation in the event, even if such liabilities, claims, demands and causes of ac tion arise in whole or in part out of the negligence of any of the above-mentioned organizations or individuals. I
attest and verify that I am physically fit and have trained sufficiently for the competition of this event, and that my physi cal condition has been verified by a licensed Medical Doctor. If signed by a parent, the parent agrees to release
and hold the above named organization and personnel harmless from and against any claims and rights, which may be asserted on behalf of the entrant. I hereby grant permission to any and all of the foregoing organizations and
personnel to use photographs, or any other record of this event for any purpose whatsoever.
Signature_______________________ Parent Signature_________________