REGISTRATION FORM
5thAnnual KILTED CANTER 5KRun/Walk
Sponsor: Belfast Rotary Club
When: Saturday, July 15, 2017, 8:30 a.m. start
Where: Belfast Area High School, 98 Waldo Avenue, Belfast, Maine
Race day registration/Packet pick up: 7:30-8:15 a.m.
1 Registration fee: $20 thru July 12, 2017 $25 race day; Active duty military $20
(Checks payable to Belfast Rotary)
2Performance t-shirts are guaranteed for all runners who register by June 30, 2017;
after that date, t-shirts are available while supplies last
NAME______2 T-SHIRT SIZE ______
(S-M-L-XL)
ADDRESS______
CITY______STATE ______ZIP ______
PHONE ( ____ ) ______E-MAIL______
GENDER ____AGE RACE DAY ____ MILITARY ____ 1FEE PAID $20 ___ $25 ___
Please review and sign the waiver below:
In signing this agreement, I specifically assume all risks of injury arising out of my/my child’s presence on RSU #71 property or the City of Belfast streets, the use of RSU #71 or the City of Belfast equipment or facilities, and my/my child’s participation in RSU #71 or the City of Belfast activities, whether on RSU #71 or the City of Belfast property or at another location, and for myself and my heirs and assigns do hereby waive, release, and agree to hold free from all claims for damages the Belfast Rotary Club and its officers, directors, members, volunteers, employees, or agents. I understand the risks and dangers involved in participating in a 5K running event; I attest that I am physically fit and trained for this event. I certify that I accept responsibility for any injury that I/my child may cause to me/my child or others. I hereby authorize the volunteers of Belfast Rotary Club to call emergency medical assistance and/or perform basic first aid procedures that are necessary in the judgment of the Belfast Rotary Club. I hereby authorize qualified medical personnel to administer necessary anesthesia and medical treatment to myself/my child in the event of an accident or medical emergency. I give the Belfast Rotary Club volunteers permission to transport me or my child by bus, van, or personal vehicle. I hereby authorize the Belfast Rotary Club to use photos and/or videos of me/my child/my family in promotional activities. I have read the agreement and I fully understand its terms, understand that I have given up substantial rights by signing it, and have signed it freely and voluntarily without inducement, assurance, or guarantee being made to me. I intend my signature to be a complete and conditional release of all liability to the greatest extent allowed by law. In consideration of this entry being accepted, I for myself, my heirs, and assigns, do hereby waive and release any rights and claims I may have against the sponsors and officials of the Kilted Canter 5K Run/Walk.
Signature ______1/2DATE ______
(Participant/Parent/Guardian)
BIB # ______
upcoming belfast rotary 5k event
Bug Run 5KRun/Walk, Saturday, August 19, 2017
E-mail -
Mail - Belfast Rotary Club, Kilted Canter 5K Run/Walk, PO Box 74, Belfast, ME 04915