5K Run / 1-Mile Fun Walk
Saturday, May 7, 2016 at 8:00AM
Volunteer Park, 4930 Alliance Church Road, Pleasant Garden, North Carolina
Last Name: ______________________________ First Name:__________________________ MI_________
Address:________________________________________________________________________________
City/State/Zip:____________________________________________________________________________
Phone:___________________________________ Email:__________________________________________
Date of Birth:_____________________________ Age on Race Day:_________ Gender: ________________
T-Shirt Size (please circle) Men: S M L XL XXL Women: S M L XL XXL Youth: S M L
T-Shirt guaranteed ONLY if application is received by April 15, 2016
Registration: Cash or checks only. Please make checks payable to “Town of Pleasant Garden.” Mail to Post
Office Box 307, Pleasant Garden, NC 27313, bring to Town Hall at 4920 Alliance Church Road during
business hours, or register onsite the day of the race.
NO REFUNDS WILL BE GIVEN!
Please check one:
5K: ______ $30 through April 15
1-Mile Fun Walk: ______ $20 through April 15
_____$35 after April 15
_____$25 after April 15
Release, Waiver, Assumption of Risk and Indemnification:
I know that participating in a road race/walk is a potentially hazardous activity and that I should not participate 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 this run. I assume all risks associated
with participating in the Run with the Hogs to benefit JDRF event on May 7, 2016, including but not limited to falls, contact with other
participants, the effects of the weather including high heat and/or humidity, traffic, the conditions of the road and all such risks being known and
appreciated by me. I, for myself, my heirs, executors, administrators and other firms, persons and corporations hereby release, indemnify and hold
harmless the Town, its agents, officers, employees, servants, organizers and volunteers (hereinafter “agents”) from any and all responsibility or
liability for any and all damage, injury or illness of any kind or nature whatsoever to all persons and to all property proximately caused by, incident
to, resulting from, arising out of, or occurring in connection with, directly or indirectly, my participation in the Run with the Hogs to benefit JDRF
event, with limited exception of harm caused by the sole negligence of agents of the Town. I acknowledge that I have read the rules & regulations
for the Run with the Hogs to benefit JDRF event and will abide by them. I release the Town and its agents from any responsibility for theft,
damage or loss in conjunction with any and all activities associated with mine/my company’s participation in the Run with the Hogs to benefit
JDRF event with the sole exception of injuries occurring due to the SOLE negligence of agents of the Town.
Photography and Video Release:
I hereby grant permission to the Town of Pleasant Garden and its agents to photograph and record video of my image, likeness or depiction and/or
that of my minor children (if applicable) and to edit, crop or retouch such photographs and videos, and waive my right to inspect the final
photographs and videos. I hereby consent to and permit photographs and videos of me and/or those of my minor children to be used by the Town
of Pleasant Garden and its agents worldwide for any purpose, including advertisement purposes, and in any medium, including print and
electronic. I understand that the Town of Pleasant Garden and its agents may use such photographs or videos with or without associating names
thereto. I further waive any claim for compensation of any kind from the Town of Pleasant Garden or its agents’ use or publication of photographs
or videos of me and/or those of my minor children (if applicable). I hereby fully and forever discharge and release the Town of Pleasant Garden
and its agents from any claim for damages of any kind (including, but not limited to, invasion of privacy, defamation, false light or
misappropriation of name, likeness or image) arising out of the use or publication of photographs or videos of me and/or those of my minor
children (if applicable) by the Town of Pleasant Garden or its agents, and covenant and agree not to sue or otherwise initiate legal proceedings
against the Town of Pleasant Garden of its agents for such use or publication on my own behalf or on behalf of my minor children. All grants of
permission and consent, and all covenants, agreements and understandings contained herein are irrevocable.
Signature:______________________________________________ Date:_____________________________
Parent/Guardian if under 18:_______________________________ Date:_____________________________
In case of emergency, please call:_____________________________ Phone: _________________________
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REGISTRANT _________________________________________ RECEIPT # ___________________________
5K Run / 1-mile Walk Registration Receipt and Event Information
(Registrant should retain this page for your records.)
Age Groups
9 & under, 10-14, 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, 70+
Packet Pick-up and Late Registration
Friday, May 6, 2016 from 4:00 – 7:00PM
Pleasant Garden Town Hall, 4920 Alliance Church Road, Pleasant Garden, NC 27313
Day of Race Packet Pick-up and Late Registration
Saturday, May 7, 2016 from 6:30 – 7:30AM
Volunteer Park, 4930 Alliance Church Road, Pleasant Garden, North Carolina 27313
* NO PETS ALLOWED AT THIS EVENT *
Race Start Times
5K at 8:00AM
1- Mile Fun Run at 8:10AM
Water
Provided at the Start and Finish lines and the mid-point of the 5K route
Awards
5K Run/Walk: Top 3 male / female per age group will receive a commemorative award
1 Mile Fun Run: Top 3 male / female will receive a commemorative award.
Finish Line
Electronic timing for the 5K Run / Walk finish line services provided by TriviumRacing.com.
Refreshments
Refreshments will be provided for race participants.
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