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2016 REGISTRATION Print form available now 

ONLINE REGISTRATION AVAILABLE - Please use link on the main page

JOHN WILT FOUNDATION 5K RUN/WALK REGISTRATION

Please Return Form to: JOHN WILT FOUNDATION 149 Callaway Court, O'Fallon, IL 62269

Or Deliver To: Toolen’s Running Start, 3220 Green Mount Crossing Dr., Shiloh, IL (618)­628­9898 Participant’s Name: ____________________________________________ RUN / WALK Address: ___________________________________________________________________
City: _______________________________________________________________________

Zip: __________ Home Ph Number ______________ Cell Ph Number _________________
Email Address: ______________________ Emergency contact /Ph Number _________________

Gender (Please Circle) MALE / FEMALE New Balance Tech Shirt SIZE (Circle One): COST (Circle One): $25 early registration

Birthday ___/___/____ Age as of 10/1/16 ________ S M L XL XXL XXXL

$30 on race day $5 additional for shipping shirt

Long Sleeve Tech Shirt Guaranteed if Registered on or before 8/31/2014 (Optional) $5 John Wilt Foundation Annual Membership
PAYMENT METHOD: AMT ________ CASH: ___ CHECK #______
(make out to John Wilt Foundation)

AUTHORIZED SIGNATURE:__________________________________________________________________

Assumption of Risk, Waiver and Release from Liability of All Claims (“Release”)

This Release covers the entirety of my participation in the 5K. I understand and acknowledge that the use of equipment and facilities arranged by Organizers and participation in the Race involves risks including, but not limited to the following: risk of property damage, bodily injury, including, but not limited to permanent disability, paralysis and possible death. These risks may result from a variety of circumstances including, but not limited to, the use or misuse of the equipment or facilities, from the activity itself, from the acts of myself or theirs, including John Wilt Foundation and O’Fallon Parks/Rec Dept (“Organizers”) and their agents, or from the unavailability of emergency medical care. I am participating in Race at my/their own free will. I understand that my decision to participate in Race is entirely voluntary. I assume full and total responsibility for all risks that may arise from my participation in Race, including by not limited to those risks described herein. I acknowledge that I have read, know and agree to all the policies and procedures relating to my participation in Race. I agree to comply with and abide by all rules, regulations and policies of the Organizes. I understand that the Organizers reserve the right to revoke or

terminate my participation in Race for any violations of any rules, regulations, or policies. I hereby release, waive, discharge, and hold harmless Organizers, and all of their affiliates, predecessors, successors, trustees, officers. directors, faculty, employees, agents and representatives past or present (hereinafter jointly referred to as “the Release Parties”) from any and all claims, suits, liabilities, judgments, cost and expenses (“Claims”) for any property damage, property loss or theft, personal injury or illness, death or other loss arising from or relating to my participation in Race. I also agree to defend, indemnify and hold harmless the Release Parties from and against any Claims arising from or related to my own acts or omissions in connection with my participation in Race. I hereby waive any protections afforded by any statute or law in any jurisdiction whose purpose, substance and/or related to my own acts or omissions in connection with my participation in Race. I hereby waive any protections afforded by any statue or law in any jurisdiction whose purpose, substance and/or effect is to provide that a general release shall not extend to claims, material or otherwise which the person giving the release does not know or suspect to exist at the time of executing the release. This means, in part, that I am releasing unknown future claims. I enter in this agreement for myself, as well as for my heirs, assigns and legal representative. I hereby consent to medical treatment for emergencies that occur during or are related to my participation in Race where I am unable o consent to such treatment. I understand the provisions of this Release apply to any treatment that might be provided to me due to my participation in the Race. I understand that I am solely responsible for any medical, health or personal injury costs relating to my participation in the Race. I understand that I am strongly encouraged to have a medical physical examination prior to participation in Race and should purchase or obtain health insurance prior to any and all participation in Race. This Release shall be governed in all respects by the laws of the State of Illinois. The parties agree to use the State of Illinois for Jurisdiction and the County of St Clair as Venue for any disputes between the parties related to this Assumption of Risk, Waiver, and Release from Liability

I HAVE READ AND FULLY UNDERSTAND THIS RELEASE AND UNDERSTAND THAT IT RELATED TO SURRENDERING AND RELEASING VALUABLE LEGAL RIGHTS.

Date: ____________ Printed Name of Participant ____________________________________________________________________________________

Signature of Participant or Parent/Legal Guardian _____________________________________________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Admin Use Only
Name __________________________ Emergency # ______________ Male/ Female Run /Walk Age Group