Third Annual HealthYorktown 5K Run/Walk & 1 Mile Kids Fun Run

HeathYorktown 3rd annual april 2013

The Hudson Valley Hospital Center and The Yorktown

Chamber of Commerce proudly present the

Third Annual HealthYorktown 5K Run/Walk & 1 Mile Kids Fun Run

Benefitting The Lakeland Education Foundation &

The Foundation for Excellence in Yorktown Education

Saturday, April 27th 2013 F.D.R. State Park, Rt. 202 (Lot 1). Yorktown, NY 7:30 am General Registration / 9:30am Fun Walk ONLY Registration

9:00am 5K Run / 9:05am Walk / 10:00am Fun Run / 10:30am Awards Ceremony

HealthYorktown 5K Run/Walk &

1 Mile Kids Fun Run Entry Form

Make check payable to The Yorktown Chamber of Commerce and mail to:

The Yorktown Chamber of Commerce, P.O. Box 632,

Yorktown Heights, NY 10598, Attn.: Arlette/5K Run/Walk

PLEASE PRINT (Please complete 1 form for EVERY MEMBER of your family / Team participating)

Name (Last) OR Team Captain: _______________________________________

First: ____________________ School District: __________________

School: _______________________ Grade: ______

Address: __________________________________________________________

City: ___________________________ State: _______ Zip: __________

Phone: ________________ Email: _____________________________

Sex: Male _____ Female _____ Age: ______ (Race Day)

Early Entry Fees: $25/Runner; $50.00/Family*; $100/Team* (up to 10 Runners) & $10/Walker or Kids Fun Run (Until April 22nd)

Race Day Entry Fee: $30/Runner; $15/Walker or Kids Fun Run

Circle One: 5K Run / 5K Walker / Kids Fun Run (up to 10 years old)

* Family & Team Registration – Please complete the additional information on the reverse of this form.

Awards Ceremony at 10:30am: First 3 Fastest Male/Female Runners, Overall and by Age Group (Ribbons for all: Kids Fun Run)

I know that running a road race is potentially a hazardous activity and that I should not enter and run 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 running in this event including, but not limited to: falls, contact with other participants, the effects of weather, including high heat and/or humidity, lighting, high winds, and extreme cold, traffic and the conditions of the road, 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, for myself and anyone entitled to act on my own behalf, waive and release The Yorktown Chamber, Super Race Systems & Events To Remember, event volunteers, and the City of Yorktown, it’s sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event even though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver. Further, I hereby grant full permission to any and all of the foregoing to use any photographs, video tapes, motion pictures, recording, or any other record of this event for any legitimate purposes. I have read the above and agree.

Signature: ______________________________________________ Date: _____________

Parents Signature (if under 18 years of age): ______________________________________ Date: _____________


Race Managed by Super Race Systems

For more information: (914) 245-4599 ~ ~


5K Run Application Final 2013