Registration for 2019 Race now open!
John Wilt Foundation
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)-628-9898
Runners may also register on www.Itsyourrace.com
Participant’s Name: ____________________________________________ RUN / WALK
Zip: __________ Ph Number __________________ Emerg Phone Number ____________________
Email Address: _____________________________________________________________________
Gender (Please Circle) MALE / FEMALE Birthday ___/___/____ Age as of 10/13/2019 ________
Hi TechShirt SIZE (Unisex Only Avail - Circle One): S M L XL XXL XXXL
COST (Circle One): $25 early registration $30 on race day $35 Virtual Runner (includes ship)
Long Sleeve Hi TechShirt Guaranteed if Registered on or before 9/1/2019
______ Free Entry with sponsorship (see www.JohnWiltFoundation.comfor sponsor form)
PAYMENT METHOD: AMT _______ CASH: ______ CHECK #______ (make out to John Wilt Foundation)
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 Veterans’ Monument (“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 to 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 ____________________________________________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ype your paragraph here.