Entry Form - Ohio River Road Runners Club

28th ANNUAL LOU COX 5K RUN/WALK
WHEN: Memorial Day Weekend, Monday, May 25, 2015. Wheelchairs start at 8:35 a.m. Runners and Walkers at 8:30 a.m. Note: Edwin C
Moses Blvd. is closed at 8:15 a.m.
LOCATION: Welcome Stadium, 1601 S. Edwin C. Moses Blvd., Dayton, Ohio. I-75 to Exit 51, Edwin C. Moses Blvd. east to Welcome Stadium/UD
Arena on your left. Parking is available at Gates C & D. Gates will be closed 15 minutes prior to the start of race.
THE COURSE: The Lou Cox Memorial 5K is one of the fastest 5Ks in the Midwest. Runners will finish inside Welcome Stadium on the track.
PACKET PICKUP: Welcome Stadium beginning from 6:30 – 8:15 a.m.
RULES: Obey all instructions from race and public safety officials. Headphones are strongly discouraged. No Pets.
Donation: $1 of every entry will go to Team RWB.
Goodies include: Short Sleeve Tech Shirt to first 800 runners in Men’s, Women’s, and Children’s sizes. Plus an American Flag.
Last Name ____________________________ First Name _________________________ DOB _________ Sex _____ Age ____
Address________________________________________
City _______________________State ____________Zip ___________
Email _________________ Phone _______________________
Emergency Contact Name _____________________________ Emergency Contact #___________________________
Runner ❏Wheelchair ❏
Shirt: Men: Small ❏Med ❏Large ❏XL ❏2XL ❏
Women: Small ❏Med ❏Large ❏XL ❏ 2XL ❏
Children: Youth Medium ❏Youth Large ❏
I would like to receive newsletters and coupons from Runners Plus ❏
Fees: $20.00 through 5/8, $25.00 through 5/20 (DO NOT MAIL AFTER 5/20), $30 on Race Day. Additional details and to register on-line at
www.orrrc.org
Make Check Payable To: ORRRC Lou Cox and Mail Along With Entry Form To ORRC Lou Cox, 94 Bethel Rd,
Centerville, OH 45458-2465
RELEASE OF LIABILITY -- READ BEFORE SIGNING: In consideration of being allowed to participate in any way the Ohio River Road Runners Club
program, its related events and activities, I the undersigned, acknowledge, appreciate, and agree that: 1. The risk of injury from the activities involved in this
program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this
risk, the risk of serious injury does exist; and, 2. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of
the releasees or others, and assume full responsibility for my participation; and, 3. I understand that bicycles, skate boards, baby joggers, roller skates or inline
skates, animals and headphones are not allowed in this event and I will abide by this rule. 4. I willingly agree to comply with the stated and customary terms and
conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation
and bring such to the attention of the Company immediately; and, 5. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin,
hereby release, indemnify, and hold harmless the Ohio River Road Runners Club, their officers, officials, agents and/or employees, other participants, sponsoring
agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity ("Releasees"), with respect to any and all injury, disability,
death, or loss or damage to person or property associated with my presence or participation, whether arising from the negligence of the releasees or others, to the
fullest extent permitted by law. I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up
substantial rights by signing it, and sign it freely and voluntarily without any inducement.
Signed:___________________________________________________ Date: __________
FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT TIME OF REGISTRATION)
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the
Releasees, and, for myself, my child and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all
liabilities incident to my minor child's involvement or participation in these programs as provided above, even if arising from the negligence of the releasees, to
the fullest extent permitted by law
. Signed:__________________________________________________ Date: __________
Participant Parent/Guardian of Participant