Paper Form - The Humane Race

Join us for a 5K Fun Run & 1 Mile Walk in Williamstown, MA.
Race starts at 10am. Run or walk, with or without your dog.
Race starts at 10am
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Sat., May 2nd, 2015
At 16 Water Street in downtown
Williamstown, MA
Check-in & Registration: 8:00am
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Collect $100 in pledges and qualify to win 3
different prizes. First Prize is a one night stay at
the Holiday Inn in Burlington, VT. Other great
prizes to come, check our website for updates!
T-shirts for first 150 runners who pre-register.
All dogs will receive an adorable bandana.
Fun finish-line festivities for the entire family.
Music, post-race food & drinks, and more!
Pre-Registration: $20 for adults; $15 for anyone 12 years old or under.
Race Day Registration: $25 for adults; $20 for 12 years old or under.
! For more information, visit us at: www.HumaneRace.org
or call 413.664-7777 "
All proceeds benefit the Berkshire Humane Society.
Official Registration Form
Race Date: Saturday, May 2nd, 2015
(Please note: One signed form is required for each participant. This form is two pages long.) Please complete this form and return with entry fee and/or donation to: The Humane Race, 28 Holden Street, North Adams, MA 01247
Pre-registration forms must be received no later than April 30th, 2015.
Last Name:_______________________________
First Name:___________________________ Age (on race day):___________
Circle Your Sex: M F
Circle T-shirt size: S M L XL Street:____________________________________________________________ Zip:________ City: ______________________________
State:____________
Phone (evenings): ___________________
(days):__________________ E-mail address:______________________________________________________
How did you learn of The Humane Race? _____________________________________________
Please circle one choice:
I will be running the 5K
I will be walking 1 Mile
For "Dog Jog" Entrants Only:
Canine Name: __________________
Wt lbs: ____
Age on race day Years: _____ months: _____
Shelter/Rescue Dog? Y N
Breed: _______________ Sex: M F Adopted from Berkshire Humane Society? Y N Typical miles dog runs: ________ Dog's longest distance run: ______ I understand that I must show license or rabies tag or certificate at check-in. ____
Registration Fees:
! $15.00 Children aged 12 & under. (pre-reg) - $20.00 (Race day)
! $20.00 for adults (pre-reg) - $25.00 (Race day)
! Please accept this additional contribution of $_______ (optional)
! I cannot participate, but please accept this donation of $_______
Please make checks payable to: "The Berkshire Humane Society"
Please Note: The Humane Race 5K Fun Run and 1 Mile Walk will be held Rain or Shine!
Waiver and Release: In consideration of my being permitted to participate in "The Humane Race" on May 2nd,
2015, the sufficiency of which I acknowledge, I, the undersigned, intending to be legally bound hereby for myself,
my heirs, assigns, executors and administrators, do hereby waive and release any and all rights, claims, demands, or
causes of action of any nature I may have against The Berkshire Humane Society, Town of Williamstown, Williams
College, and/or their directors, employees, agents, officials, volunteers, sponsors or any other representatives for any
and all injuries or other damages of any kind that may be suffered by me or my dog in this event, from the date of
this event forward.
I hereby certify that my dog and I are physically fit and have sufficiently trained for the competition of this event. I
acknowledge that any injuries sustained by me or my dog during the course of this event may be caused by or arise
out of risks inherent to a cross-country race, of which I have full knowledge and which I assume. I further certify that
all information and or documentation that I provided in connection with this application is true and accurate as of the
date of the scheduled event. I will be responsible for the conduct of my pet, for cleaning up after my pet and for
keeping my pet leashed at all times. I agree to indemnify and hold all sponsors of this event harmless against any and
all claims, demands, or causes of action of any kind for any accident, injury or damage whatsoever caused to any
person or property by me or my dog arising, directly or indirectly, prior to, during, or after the course of this event. I
will additionally permit the free use of our names, pictures or likeness in broadcasts, newsletters or promotional
materials.
I understand that there may be dogs participating in this event. I understand the terms of this Waiver and Release and
by my signature below affirm that I am signing this waiver and release freely and voluntarily.
______________________________ _______________________________
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Name (please print)
Date
Signature (Parent/Guardian if under age 18)
_____________________________________
_________
Signature of Dog Owner if not Companion Runner
Date