Date: Time:


HUG AN ATHLETE 5K REGISTRATION FORM Sunday, February 27, 2017


1:00pm Race Start


Location: Doty Park, Belvidere All n


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____________________________________________ NAME


____________________________________________ ADDRESS


____________________________________________ CITY, STATE, ZIP


____________________________________________ PHONE


____________________________________________ EMAIL (receive race updates)


___________________ BIRTHDATE (MM/DD/YR)


SHIRT SIZE (circle): YOUTH ADULT


S S


M L M L


EMERGENCY INFORMATION: MALE FEMALE


Regular* Late


Race Day Sponsor


ds ben t NA BeSR- lvider ark Dis ictr t ics athlt


e P at cause! Sign me up!


Yes, I would like to register for the Hug an Athlete 5K run/walk/roll:


$25.00 register between 11/25/16-1/31/17 $30.00 register between 2/1/17-2/23/17


$35.00 register at Race on 2/26/17 or packet pick up on 2/24 & 2/25.


$FREE—Contact us for more information! *will be guaranteed a shirt and swag bag if registered by 1/31/17.


Make checks payable to “Belvidere Park District”. You may pay be cash or credit card if you drop off your entry form by the options below.


XL 2XL Individual listed as the


emergency contact, must not be someone who is also participating in the Hug an Athlete 5K.


____________________________________________ EMERGENCY CONTACT NAME


__________________________________________________________ EMERGENCY CONTACT PHONE NUMBER


For Office Use Only: Date Entry Received:


Date Entry Entered in RecTrac: Date Entry Entered in Timing:


Participation Waiver: I know that participating in a road race is a potentially dangerous activity. I should not enter this race unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the race. I assume all risks associated with participating in this event including, but not limited to, falls, contact with other participants, the effects of the weather, including extreme cold/snow/ice, traffic, and the conditions of the paths, all such risks being known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of your accepting my entry, I form myself and anyone on my behalf, waive and release the Belvidere Park District and all race sponsors, supporters, officials, their representatives and successors from all claims of liabilities of any kind arising out of this event for any legitimate purpose.


________________________________________________________ 5K PARTICIPANT SIGNATURE (PARENT SIGNATURE IF UNDER 18)


________________ Initial _________ ________________ Initial _________ ________________ Initial _________


Notes: ______________________________________________________________


Drop Off Entry From to: Belvidere Park Admin. Bldg. NASR-Belvidere Facility


Mail* Entry From to: 6581 Revlon Drive Belvidere, IL 61008


*All mail in registration must be post-marked by 2/28/17. NASR-Belvidere Park District ~ 6581 Revlon Dr ~ Belvidere, IL 61008 ~ 815-547-5711 x 14 ~ Fax: 815-544-4648


1006 W. Lincoln 6581 Revlon Dr.


M-F 9am-5pm M-F 3:30pm-6pm


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