Race Registration Form
Chinklacamoose 5K Fun Run/Walk
June 20, 2015 9:00 AM
One registration form is required per participant.
You can also register online at www.clfdccd.com
Last Name ______First Name______
Address______
City______State______Zip______
Phone______Email______
Date of Birth____/____/______Gender______
Payment
____Adult Pre-registration until 6/1/15 $15.00
____Adult Registration from 6/1/15 through Race Day $20.00
____Youth 17 & Under Pre-registration until 6/1/15 $10.00
____ Youth 17 & Under Registration from 6/1/15 through Race Day $15.00
Sub-Total______
Accident waiver and release of liability / photo release:
I know that running a road race is a potentially hazardous activity. I should not enter and run unless I am physically fit, medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all risks associated with running this event including, but not limited to: falls, contact with other participants; the effects of the weather; including high heat and/or humidity; traffic; and the conditions of the road; all such risks being know and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I for myself and anyone entitled to act on my behalf, waiver and release Clearfield County Conservation District, all sponsors, advertisers, their representatives, and successors, their officers, directors, agents, and employees and volunteers from all claims, or liabilities of any kind arising out of my participations in this event. I grant permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose.
Parent or Guardian waiver for minors (under 18 years old) if applicable:
The undersigned parent and natural guardian or legal guardian does herby represent that he/she is, in fact, acting in such a capacity and agrees to save and hold harmless and indemnify each and all parties referred to above from all liability, loss, cost, or damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to act and release said parties on the behalf of the minor and the parents or legal guardian. Minors accepted only with parent or guardian’s signature.
Print Name______Date ______
Signature______
Parent/Legal Guardian must sign if participantis under the age of 18
For questions please contact us on our website www.clfdccd.com or phone 814-765-2629.
Send your completed form to: Clearfield County Conservation District, 511 Spruce Street, Suite 6, Clearfield, PA 16830.