D.A.R.E To Run For BACKSTOPPERS
Saturday, November 3rd, 2012
5K Run/Walk & 10K Run – 9:00 am
Half Mile Kids Fun Run – 10:00 am
Village of MillstadtPark
301 North Jefferson, Millstadt Illinois
villageofmillstadt.org (Village Departments tab) & millstadtpolice.org
Race Day Registration: 8:00 am – 8:45 am
Early Packet Pickup: Nov 1std2nd, 9:00 am – 5 pm @ Millstadt Village Hall, 111 W. Laurel
* Top male & female winner of both the 5K & 10K receive trophies.
* The top 3 finishers in each age division receive medals. (No duplication of awards)
* Age groups for male & female – 13 & under, 14-19, 20-29, 30-39, 40-49, 50-59, 60 & over.
* Emergency Responder Award – First active Firefighter, EMT, or Police Officer to finish 5K & 10K
Timing provided by Toolen’s Running Start
Questions or sponsorship opportunities: Contact Lt. Alan Hucke 618-781-6944 or
All proceeds benefit BackStoppers & Millstadt Police Youth Programs
Millstadt Fire Department BBQ stand available: Benefits BackStoppers
* * * * * * * * * * * * * * * * * * * * * * * * * *
Make checks payable to: MILLSTADT POLICE DEPARTMENT, 108 W. White St., MillstadtIL62260
Name Address
City/State/ZipPhone
Sex Age (as of 11/3/12)Email
If you are an active firefighter, EMT, or police officer, indicate dept.______
Entry Fees:5K or 10K$20 if postmarked by October 13th (Wicking T-shirt guaranteed)
Circle Preferred Race $25 if postmarked October 14th thru race day
Fun Run (12 & under)$10 (all kids will receive a participation medal)
Shirt Size: (5K/10K Only) _____Small ______Medium _____Large _____X-Large _____XX-Large
WAIVER, RELEASE & INDEMNIFICATION (In consideration of the acceptance of my entry in the Run/Walk, Fun Walk). I hereby agree to comply with all rules and regulations and event instructions of the Run/Walk, Fun Walk and its Events Committee members. 2. For myself, my executors, administrators, heirs, next of kin. I hereby: (a) Waiver and release any and all claims that I may have against the Run/Walk, Fun Walk, its Events Committee, their officers, directors, members, volunteers, employees, the municipality of Millstadt, Village of Millstadt and Board including any and all claims for damage caused by the negligence of any of them, arising out of my participation in the event and its related activities, together with any cost including attorney’s fees that may be incurred as a result of any such claim whether valid or not and, (b) Indemnify and hold harmless the releases and each of them against any such claim that I or my guests or any one or more of my or their executors, administrators, heirs, next of kin may have or assert and 3. I hereby acknowledge that I have sole responsibility for my personal possessions and athletic equipment during the Run/Walk, Fun Run event and its related activities. 4. I hereby acknowledge that participation in the Run/Walk, Fun Run event carries with it potential hazard. I therefore release the Run/Walk, Fun Run Events Committee, their officers, directors, members, volunteers, employees, agents, the municipality of any liability in the event of injury or death during the event. 5. I hereby attest and verify that I am physically fit and have sufficiently trained for this competition and that my physical condition has been verified by a licensed medical doctor. 6. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident and/or illness during the Run/Walk, Fun Run.
I agree to the above waiver conditions:
Signature Date
CONSENT OF MINOR’S PARENT/GUARDIAN