2016 CHICKS RUN ENTRY FORM.cdr

CHICKS RUN
JUST FOR
WOMEN 5K
CHICKS RUN
JUST FOR
WOMEN 5K
BLUFFTON PARKS DEPARTMENT
THURSDSAY, JUNE 9TH AT 7:00 P.M.
BLUFFTON PARKS DEPARTMENT
THURSDSAY, JUNE 9TH AT 7:00 P.M.
BLUFFTON CITY GYM (128 E. MARKET ST.)
BLUFFTON CITY GYM (128 E. MARKET ST.)
SERIES SPONSORS: CAYLOR NICKEL FOUNDATION,
INDIANA PHYSICAL THERAPY, PROUGH DESIGN BUILDERS,
PRETZELS, INC. iAB FINANCIAL
A “Just for Women”, “Just for Fun” 5k Fun Run on Bluffton’s River Greenway.
Yes we have a timing clock but awards are given to those who inspire us with
their stories, their enthusiasm, and who RUN and WALK for the pure LOVE
of being active and MOVING with their GIRLFRIENDS. Everyone is welcome,
whether you run, walk, skip, or dance your way to the finish line. So....Grab a
friend, neighbor, co-worker, mother, daughter, aunt or grandma and join us
for the CHICKS RUN !
PHOTO STOPS * REFRESHMENTS * PRIZES * AWARDS
SERIES SPONSORS: CAYLOR NICKEL FOUNDATION,
INDIANA PHYSICAL THERAPY, PROUGH DESIGN BUILDERS,
PRETZELS, INC. iAB FINANCIAL
A “Just for Women”, “Just for Fun” 5k Fun Run on Bluffton’s River Greenway.
Yes we have a timing clock but awards are given to those inspire us with their
stories, their enthusiam, and who RUN and WALK for the pure LOVE of being
active and MOVING with their GIRLFRIENDS. Everyone is welcome,
whether you run, walk, skip, or dance your way to the finish line. So....Grab a
friend, neighbor, co-worker, mother, daughter, aunt or grandma and join us
for the CHICKS RUN !
PHOTO STOPS * REFRESHMENTS * PRIZES * AWARDS
CHICKS RUN REGISTRATION(PLEASE PRINT)
CHICKS RUN REGISTRATION(PLEASE PRINT)
Name: __________________________________________________
Name: __________________________________________________
Email: __________________________________________________
Email: __________________________________________________
Address: ________________________________________________
Address: ________________________________________________
Phone: _____________________ Age _______
Phone: _____________________ Age _______
Register For ____ $5.00 Chicks Run Only (No T-Shirt)
OR ____ $15 Chicks Run + T-Shirt (Circle Size)
Type: ___ Unisex ___ Women’s (more fitted)
SIZE: Youth Small, Youth Med, S M L XL
Register For ____ $5.00 Chicks Run Only (No T-Shirt)
OR ____ $15 Chicks Run + T-Shirt (Circle Size)
Type: ___ Unisex ___ Women’s (more fitted)
SIZE: Youth Small, Youth Med, S M L XL
2XL
If you are on a Team
Team Name: _________________________________________
Make Checks Payable and Return to
Bluffton Parks Department, 128 E Market St. Bluffton, IN 46714
Please Sign Attached Waiver
2XL
If you are on a Team
Team Name: _________________________________________
Make Checks Payable and Return to
Bluffton Parks Department, 128 E Market St. Bluffton, IN 46714
Please Sign Attached Waiver
WAIVER AND RELEASE OF LIABILITY I acknowledge that this
athletic event is an extreme test of a person's physical and mental limits and carries with it the
potential for death, serious injury and/or property loss. The risks include, but are not limited
to, those caused by terrain, facilities, temperature, weather, lack of hydration, condition of
athletes, equipment, vehicular traffic, and actions of other people including, but not limited to,
participants, volunteers, spectators, coaches, event officials, event monitors, and/or producers
of the event. These risks are not only inherent to the athletes , but are also present for
volunteers. I hereby assume all of the risks of participating in and/or volunteering at this
event. I certify that I am physically fit, have sufficiently trained for participation in the event
and have not been advised otherwise by a qualified medical person. I acknowledge that this
Waiver and Release of Liability form will be used by the event holders, sponsors and
organizers of this event and that it will govern my actions and responsibilities in connection
with this event.
In consideration of my application and for permitting me to participate in this event, I
hereby take action for myself, my executors, administrators, heirs, next of kin, successors,
and assigns as follows: (A) I HEREBY WAIVE, RELEASE AND DISCHARGE the City of
Bluffton, Indiana, the Mayor of Bluffton, the Common Council of the City of Bluffton, the
Bluffton Board of Public Works and Safety, the Department of Parks and Recreation of the
City of Bluffton, the members of the Board of Parks and Recreation for the City of Bluffton, the
event holders, the event sponsors, Wells County, the Board of Commissioners of Wells
County, the Wells CountyCouncil, and any agents, successors, assigns or employees of any
of the foregoing (hereinafter collectively “the Releasees”) from any and all claims or liabilities
for death, personal injury, property damage, theft or damages of any kind, whether or not
attributable to the negligence of the Releasees, which arise out of or are in any way related to
my participation in this event or traveling to and from this event. (B) I HEREBY INDEMNIFY
AND HOLD HARMLESS the Releasees as previously identified from any and all liabilities or
claims made by other individuals or entities as a result of any of my actions during this event
and/or arising out of my travels to and from this event.
I hereby consent to receive medical treatment, which may be deemed advisable in the
event of injury, accident and/or illness during this event. I understand that at this event or
related activities, I may be photographed. I agree to allow my photo, video or film likeness to
be used for any legitimate purpose by the event holders, producers, sponsors, organizers
and/or assigns.
This Waiver and Release of Liability shall be construed broadly to provide release and
waiver to the maximum extent permissible under applicable law.
I hereby affirm that I am 18 years of age or older, that I have read and understand the
foregoing Waiver and Release of Liability and/or have had the opportunity to discuss it with
race officials to my satisfaction.
I hereby consent to receive medical treatment, which may be deemed advisable in the
event of injury, accident and/or illness during this event.
I understand that at this event or related activities, I may be photographed. I agree to allow
my photo, video or film likeness to be used for any legitimate purpose by the event holders,
producers, sponsors, organizers and/or assigns.
I understand that my entry fee into this event is non-refunable. In the unlikely event that it
is cancelled due to extreme weather conditions or safety concerns, my entry fee will be used a
donation to the Bluffton Parks Department.
WAIVER AND RELEASE OF LIABILITY I acknowledge that this
athletic event is an extreme test of a person's physical and mental limits and carries with it the
potential for death, serious injury and/or property loss. The risks include, but are not limited
to, those caused by terrain, facilities, temperature, weather, lack of hydration, condition of
athletes, equipment, vehicular traffic, and actions of other people including, but not limited to,
participants, volunteers, spectators, coaches, event officials, event monitors, and/or producers
of the event. These risks are not only inherent to the athletes , but are also present for
volunteers. I hereby assume all of the risks of participating in and/or volunteering at this
event. I certify that I am physically fit, have sufficiently trained for participation in the event
and have not been advised otherwise by a qualified medical person. I acknowledge that this
Waiver and Release of Liability form will be used by the event holders, sponsors and
organizers of this event and that it will govern my actions and responsibilities in connection
with this event.
In consideration of my application and for permitting me to participate in this event, I
hereby take action for myself, my executors, administrators, heirs, next of kin, successors,
and assigns as follows: (A) I HEREBY WAIVE, RELEASE AND DISCHARGE the City of
Bluffton, Indiana, the Mayor of Bluffton, the Common Council of the City of Bluffton, the
Bluffton Board of Public Works and Safety, the Department of Parks and Recreation of the
City of Bluffton, the members of the Board of Parks and Recreation for the City of Bluffton, the
event holders, the event sponsors, Wells County, the Board of Commissioners of Wells
County, the Wells CountyCouncil, and any agents, successors, assigns or employees of any
of the foregoing (hereinafter collectively “the Releasees”) from any and all claims or liabilities
for death, personal injury, property damage, theft or damages of any kind, whether or not
attributable to the negligence of the Releasees, which arise out of or are in any way related to
my participation in this event or traveling to and from this event. (B) I HEREBY INDEMNIFY
AND HOLD HARMLESS the Releasees as previously identified from any and all liabilities or
claims made by other individuals or entities as a result of any of my actions during this event
and/or arising out of my travels to and from this event.
I hereby consent to receive medical treatment, which may be deemed advisable in the
event of injury, accident and/or illness during this event. I understand that at this event or
related activities, I may be photographed. I agree to allow my photo, video or film likeness to
be used for any legitimate purpose by the event holders, producers, sponsors, organizers
and/or assigns.
This Waiver and Release of Liability shall be construed broadly to provide release and
waiver to the maximum extent permissible under applicable law.
I hereby affirm that I am 18 years of age or older, that I have read and understand the
foregoing Waiver and Release of Liability and/or have had the opportunity to discuss it with
race officials to my satisfaction.
I hereby consent to receive medical treatment, which may be deemed advisable in the
event of injury, accident and/or illness during this event.
I understand that at this event or related activities, I may be photographed. I agree to allow
my photo, video or film likeness to be used for any legitimate purpose by the event holders,
producers, sponsors, organizers and/or assigns.
I understand that my entry fee into this event is non-refunable. In the unlikely event that it
is cancelled due to extreme weather conditions or safety concerns, my entry fee will be used a
donation to the Bluffton Parks Department.
Date___________
Signature ___________________________________________
Printed Name_____________________________________________
Date___________
Signature ___________________________________________
Printed Name_____________________________________________
PARENT/GUARDIAN WAIVER AND RELEASE OF LIABILITY FOR MINORS
I, the undersigned, being the parent or legal guardian of the participant who is less than 18
years of age, hereby represent that I have read and understand the foregoing Waiver and
Release of Liability. In my capacity as parent./guardian of the participant, and on behalf of the
participant, the participant's estate, assigns and successors in interest, I hereby agree to
waive and release from liability each of the Releasees as identified above in the same manner
as indicated above.
________________________________
_____________________________________
Parent/Guardian Signature for Minor
Printed Parent/Guardian Name
PARENT/GUARDIAN WAIVER AND RELEASE OF LIABILITY FOR MINORS
I, the undersigned, being the parent or legal guardian of the participant who is less than 18
years of age, hereby represent that I have read and understand the foregoing Waiver and
Release of Liability. In my capacity as parent./guardian of the participant, and on behalf of the
participant, the participant's estate, assigns and successors in interest, I hereby agree to
waive and release from liability each of the Releasees as identified above in the same manner
as indicated above.
________________________________
_____________________________________
Parent/Guardian Signature for Minor
Printed Parent/Guardian Name