Event will be held Saturday, April 30, 2016 at the Hess Fields, Danville. Registration begins at 8:30 am and race kick off time is 10 am.
register online: PARunners.com
Age (at race date)/gender: _____________________________
City, State, Zip: ___________________________________
Phone ( ) - _______ - ________
Emergency Contact (name and phone number): ____________________________________
T-Shirt size(s) (circle one): Youth M Youth L Adult S Adult M Adult L Adult XL
Entry Fee: Please make your check payable to Momma K’s Kids. Return form and fee to: Kayla James at PO Box 15, Danville, PA 17821. Any questions contact Kayla at firstname.lastname@example.org.
I, ____________________________ (please print), in consideration of myself or my child being permitted to participate in the activity below in any way, hereby for myself, my family members, heirs, and personal representatives, successors or assigns, assume any and all risks which might be associated with this event. I further waive, release, discharge and covenant not to sue the American Cancer Society, East Central Division Inc., (“ACS”) its affiliates, directors, officers, members, sponsors, organizers, employees, volunteers, legal representatives, agents, successors and/or assigns and all volunteers with the run, for any and all claims, costs, including attorney’s fees, demands, causes of action, suits, injuries, damages of any kind whatsoever, or death, sustained by me, which arise out of my participation in this event. I also agree to the use of film, photo, audio or videotape of my participation in this event for any reason.
I understand that there are risks involved with my participation in a 5 Kilometer Run or any other type of distance running or hiking event. Falling, tripping, collision with other occupants and objects, dehydration, loss of breathe, strained muscles, asthma attacks, heart attacks or other types of potentially hazardous events including death are possible during involvement in such an activity. This constitutes my understanding of that involvement in a potentially dangerous activity with accompanying risks of personal injury or death and loss or damage to personal property, and I hereby voluntarily assume those risks.
Activity: Colors of Hope 5K walk/run at the Hess Field Recreation Area taking place on the 30th day of April 2016.
This instrument shall remain in full force and effect indefinitely and shall inure to the benefit of my family members, heirs, agents, legal representatives, successors and/or assigns.
I have read and understand the foregoing provisions of this WAIVER, RELEASE AND COVENANT NOT TO SUE and I have executed this instrument voluntarily on this date.
Participant’s Full Name
Guardian’s Full Name
(If Participant is under 18)
Emergency Dial 911
Non Emergency Dispatch
Street Department 570-275-5338
Susquehanna River Level
PA State Website
PA State Senate Website
US Senate Website
PA House of Representatives Website
US House of
Northumberland County Website