Panhandle Public Health District & Chadron Public Schools

Panhandle Run for Youth 5K & Fun Run

May 17^th 2014

MUST Register by APRIL 25, 2014, to guarantee event T-shirt.

Race day registrations will be accepted. (Cannot guarantee shirts.)

Proceeds will help sustain Panhandle Girls on the Run and Morning Marathon Club

Make checks payable to Chadron Public Schools

Please return to (mail or drop off):

Chadron Primary School, Attn: Linda Rischling

732 Ann St, Chadron, NE 69337

PLEASE PRINT

Participant  Full  Name: ______________________________________________________                  

Mailing address: _____________________________   Email_________________________

Run Day Phone number: ______________________  Run Day Age: _________   Gender:    M       F

Youth (under 14) entries are $20, this includes an event t-shirt and finisher medal if registered by April 25.  Youth must also run with registered Run Buddy.  A Run Buddy is someone over the age of 18 who will be responsible for the participant during the event.

Adult entries are $20 and includes an event t-shirt if registered by April 25.      

Circle ONE:                 J  ADULT  5K – $20                                 J  ADULT Fun Run – $20

J   Youth 5K (age 14 & under)  – $20                   J  Youth Fun Run (age 14 & under) – $20

Please indicate t-shirt size below (if registered by April 25):

Youth Sizes:                 Small               Medium          Large

Adult Sizes:                  Small               Medium          Large               XLarge

Add $3 per size up:      XXLarge                      XXXL

WAIVER: I know that entering the Panhandle Public Health Run for Youth is a potentially hazardous activity. I should not enter unless I am medically able and properly trained to run or walk the event. I agree to abide by any decision of the race official relative to my ability to participate. I assume all risk associated with this event, including but not limited to: falls, contact with other participants, the effect of the weather including high humidity, and any traffic or unnatural conditions of the road race course, such as rough surfaces or motorists. I, for myself and dependents entered in the event if under 18, and anyone entitled to act on my behalf, waive and release Girls on the Run of Nebraska, Panhandle Public Health, Chadron Public Schools, all sponsors, race officials, their representatives and successors from claims and liabilities of any kind arising out of my participation or my dependents participation in this event, though that liability may arise out of the negligence or carelessness on the part of the persons named in the waiver.

Further, I grant permission to all of the foregoing to use any photographs, motion pictures, or other record of this event for any legitimate purpose without compensation to me.

Date________________    Signature  of participant __________________________________________________

(Parent or guardian signature of participants under 18)