DASH 4 DAN (Race in honor of Daniel Christophe, Jr.)
PLEASE PRINT THIS OUT AND RETURN IT TO ONSITE REGISTRATION ON MAY 8
REGISTER ON SITE THE DAY OF THE RACE!!
REGISTRATON OPENS AT 8:30 A.M. ON THE 8TH FOLLOWED BY THE RACE AT 10:00 A.M.
Groups of 6+ should contact event chairs for pricing/registration information
Name____________________________________Address___________________________________________
City_____________________ State______ Zip ___________
Telephone Number________________________________ E-mail ___________________________________________
Entry fee includes t-shirt, care package and breakfast. Check your registration choice below:
__Individual Adult (15 and up) $30 __ Individual Youth (14 and under) $20
__Family Registration (up to 4 people) $80 __Additional family members @ $15 $___________
__I would like to make a donation $___________
TOTAL AMOUNT ENCLOSED $___________
Please make payment by CASH or check payable to St. Peter the Apostle (note “Dash for Dan” in the memo) and submit payment to: Attn: Dash for Dan St. Peter the Apostle School 500 N. Cherry Itasca, IL 60143
Participant/Family Las t Name______________________
Participant Name(s) Age/Sex (as of 05/08/10)
1_____________________________ _____ M F 2____________________________ _____ M F
3_____________________________ _____ M F 4____________________________ _____ M F
5_____________________________ _____ M F 6____________________________ _____ M F
T-shirt size (if registering as family, please indicate number of t-shirts per size)
Adult: _____ S _____ M _____ L _____ XL _____2X
Youth: _____ S _____ M _____ L
RELEASE AND ASSUMPTION OF RISKMUST BE SIGNED WITH APPLICATION
Release& Assumption of Risk
As a participant, I agree to defend, protect, indemnify and hold harmless St. Peter the Apostle against and from all claims arising from the negligence or fault of St. Peter the Apostle or any of its agents, family members, officers, volunteers, helpers, partners, organizational members or associates which arise out of the participating in any and all activities connected with or associated with St. Peter the Apostle.
Additionally, the Dash for Dan Committee agree to protect, defend, hold harmless and fully indemnify St. Peter the Apostle for any claim or cause of action whatsoever arising as a result of participating in the Dash for Dan 5KEvent that is brought against St. Peter the Apostle by the Dash for Dan Committee or their family members whether such claim arises from the alleged negligence of St. Peter the Apostle, its employees or agents or Dash for Dan Committee members negligence. If any portion of this agreement is held invalid, it is agreed that the balance thereof, shall continue in full legal force and effect.
I know that running or walking a road race is a potentially hazardous activity. I should not enter and run/walk unless I am medically able and properly trained. I assume all risks associated with running in this event including, but not limited to: falls, contact with other participants, the effects of weather, including heat and/or humidity, traffic, and the conditions of the road/path. I have read and fully understand the above waiver.
I further grant permission to use any photographs, motion pictures, recordings or any other records of this event for any legitimate reason.
I have carefully read this Release and Assumption of Risk and fully understand its contents. I voluntarily sign it and realize that this will bind me, my heirs, and personal representatives.
(note: parent or guardian must sign if participant is less than 18 years of age. For “family registration” all participating adults must sign, participating parent signature will additionally serve as a Release and Assumption of Risk for family participants less than 18 years of age)
Date__________________________
Signature:___________________________________________
Signature:___________________________________________
Signature:___________________________________________
Signature:___________________________________________
Signature:___________________________________________
Signature::___________________________________________
Event Co-Chairs: Diane Flaherty or Anna Prell (630-250-0201) (630-773-0698) web site: dash4dan.com e-mail address: dashfordan@aol.com