Concord Junior High School 5K Race / 1m Fun Run benefitting the Make-A-Wish Foundation Race starts and ends @ the C.J.H.S campus Saturday, March 25, 2017, 11:00 a.m. RAFFLE * AWARDS * MUSIC * SNACKS * FUN * PHILANTHROPY Name: _____________________________________________
Circle one: 5k Race 1m Fun Run
Address: ___________________________________________ Phone Number: ______________________ City, State, Zip: _____________________________________________ T-shirt size: YL S M L XL 2XL (T-shirts available to the first 300 registered)
E-mail: _________________________________________
Registration Cost $10 per participant
$35 Family - up to 5 members
Day of race registration - $15 per person for ALL
(If purchasing the family package...every member must complete a registration form)
Check or Cash accepted. Checks made payable to: M ake-A-Wish Foundation Registration packets can be picked up inside Concord Junior High School on day of race between 9:00-10:30. Park in back of school and enter at door 12. Please return this form with payment by mail or in person to: Concord Junior High School 59397 CR 11 Elkhart, IN 46517 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RELEASE OF LIABILITY (Adult – 18 and older) In consideration of the acceptance of this entry, I waive all claims for myself and my heirs against Concord Community Schools, Concord Junior High School, sponsors, cooperating, coordinating groups, their employees, trustees, and agents acting on those entities’ behalf, and any individuals associated with this event and will hold them harmless for any injuries or claims that may result from my participation in this event. I give my permission for the media to use my name and photograph in the newspaper, broadcast, telecast of this event without limitation or obligation. I certify that I am physically fit for this event and understand the risks involved in participating in this event.
Signature ____________________________________________ Date ____________________________
PARENT / GUARDIAN CONSENT FORM AND LIABILITY WAIVER (18 and under) Participant name: _________________________________ Birth Date: __________________Sex: _______ Parent/Guardian Name: ____________________________________ Home Phone: ___________________ I, ________________________________ , grant permission for my child, ______________________________ , to participate in the CJHS Make-A-Wish 5k Race/1m Fun Run/Walk. As parent and/or legal guardian, I remain legally responsible for any action taken by that child that causes any injury or damage. On behalf of myself and my child, I waive all claims for myself, my child, and our heirs against Concord Community Schools, Concord Junior High School, sponsors, cooperating, coordinating groups, their employees, trustees, and agents acting on those entities’ behalf, and any individuals associated with this event and will hold them harmless for any injuries or claims that may result from my child’s participation in this event. I give my permission for the media to use my child’s name and photograph in the newspaper, broadcast, telecast of this event without limitation or obligation. I certify that my child is physically fit for this event and understands the risks involved in participating in this event.
Parent/Guardian Signature__________________________________ Date ________________________
