Você está na página 1de 2

Lewis County Hospital Foundation

Spring Into Health 5K


Saturday, April 7, 2018
at the Lewis County Fairgrounds Pavilion

Proceeds to benefit 2018 Uncle Sam’s Boat Tour for LCGH Nursing Home Residents
REGISTRATION INFORMATION: The 5K start time will be 9:30am
Pre Registration through April 4th, 2018 $25 Awards will be given to the 1st place 5K
Includes race, t-shirt, refreshments, and custom race medal!
participant in each age/gender category.
Day of Race Registration (8am-9am) $30
NEW ADDITIONS TO OUR 2018 EVENT:
** Register online at runsignup.com **
Medals will be given to all of our participants.
Registration Check-In from 8am until 9am
Race Timing will be provided by Albany Running
at the Lewis County Fairgrounds Pavilion
Exchange, Results will be available electronically
5K Route: after the event.
Exit the fairgrounds Dewitt Street Gate, up Summit TEAM Registration is encouraged!
Avenue to N. State Street. N. State Street south to Sign up with a group of 2 or more persons, and you
Trinity Ave, Left onto Trinity out to E. State Street. will be eligible for our Team Spirit and Team
Left onto E.State Street out to State Route 812. Costume Awards!
Turn left onto 812 and go up to Bostwick St., right
Be sure to note your team name and members on
onto Bostwick, & finish back at the fairgrounds.
your registration form.
ENTRY FORM

Name:____________________________________ Address: __________________________________


State/Zip: _________________________________ Phone: ___________________________________
Email: ____________________________________ Gender: (Circle One) Male Female
Age Group: (Circle One): Under 10 11-20 21-30 31-40 41-50 51-60 61 & Over
□ 5K Walk $25 Pre-Registration T-Shirt Size: □ S □M □L □ XL □ 2XL
□ 5K Run $25 Pre-Registration T-Shirt Size: □ S □M □L □ XL □ 2XL
** Event Day Registration is $30.00, Shirt not guaranteed
Team Name & Members: ___________________________________________________________________
Please make checks payable to: Lewis County Hospital Foundation and mail completed
forms to: 7785 North State Street, Lowville, NY 13367. For additional information, please
contact the Hospital Foundation at 315-376-5110 or jrhubart@lcgh.net.
** Supervision of children will not be provided during the event.
All participants must complete and sign and an acknowledgement of risk and accident waiver
and release of liability on the back of this form prior to the race.
ACKNOWLEDGEMENT OF RISK ACCIDENT WAIVER AND RELEASE OF LIABILITY
In consideration of you accepting this entry, I, the participant, intending to be legally bound and hereby
waive or release any and all right and claims for damages or injuries that I may have against the Event Direc-
tor, RunSignup.com, and all of their agents assisting with the event, sponsors and their representatives and
employees for any and all injuries to me or my personal property. This release includes all injuries and/or
damages suffered by me before, during or after the event. I recognize, intend and understand that this re-
lease is binding on my heirs, executors, administrators, or assignees. I also authorize the use of photographs
or videos that include my image for promotional, informational, or other reasons deemed to be in the best
interest of the event. I certify as a material condition to my being permitted to enter this race that I am physi-
cally fit and sufficiently trained for the completion of this event and that my physical condition has been veri-
fied by a licensed Medical Doctor. By submitting this entry, I acknowledge (or a parent or adult guardian for
all children under 18 years) having read and agreed to the above waiver. I HAVE READ THE ABOVE OR I AC-
KNOWLEDGE, IF VERIFIED THAT I HAVE HAD THIS DOCUMENT READ TO ME AT MY REQUEST AND BY SIGN-
ING IT I AGREE IT IS MY INTENTION TO PARTICIPATE IN THE INDICATED ACTIVITY AND I UNDERSTAND AND
ACCEPT ALL THE RISKS INVOLVED.

DATE: ____________________

LOCATION: Lewis County Fairgrounds

PARTICIPANT’S FULL NAME (print)______________________________________________________

DATE OF BIRTH: __________________________________

ADDRESS: _________________________________________________________________________

PARTICIPANT SIGNATURE: ____________________________________________________________


(Parent/Guardian Signature if participant is under 18 years of age.)