3376 Guyanoga Road
Branchport, NY 14418
When: July 4th, 2017 @ 8:00am
5K Cost – Please select one:
____ $25.00 pre-registration before June 30 ____ $30.00 late/race day
Kid’s Fun Run FREE (t-shirts $10.00) – 1 mile race
To register by mail, fill in the fields below, print out this form and mail this form and your check to the address below. Print out one copy per entrant. Each participant, or their legal guardian, must sign the waiver at the bottom.
Make checks payable to: Branchport UMC
c/o Dave Thorn
3988 Belknap Hill Road
Branchport, NY 14418
Race day registration/Check-in: 7:00-7:45am Awards: Prizes will be awarded in age group categories for male and female top finishers.
City: ___________________________ State: _____________________Email: _________________________
Male: __________ Female: ____________ Age: ___________ Phone Number: ___________
Yes, I want a FREE t-shirt – ____ S ____M ____L ____XL (if registered by June 15th)
Total Cost ______ race fee
Waiver: I know that running is a potentially hazardous activity that carries the risk of property damage, personal injury or death. I know I should not run this event unless I am medically able and I am aware of and assume all risks associated with running in this race. I understand that I, or the person(s) I am responsible for, will be subject to variable weather and course conditions. I assume all risks associated with this event including, but not limited to, property damage, personal injury or death that may result from, including, but not limited to, personal medical conditions, falls, contact with other persons, traffic and road conditions. Therefore I, for myself, or the person(s) I am responsible for, release and hold harmless the Branchport United Methodist Church, The Upper New York Conference, and their representatives, all sponsors, agencies, municipalities and any other persons involved with the event, from any liability for any and all property damage, personal injury or death that may occur as a result of my/his/her participation in this event. I understand that my entry fee is NON-REFUNDABLE. I also understand I may be photographed while participating in this event.
Signature: ______________________________________________________ Date: ______________
Parent or guardian must sign if participant is under 18 years of age