Run For Your Life 5K Run / 1.5 Mile Fun Walk Registration Form

Run For Your Life 5K Run / 1.5 Mile Fun Walk Registration Form
Entry Fees: Non-refundable
Early Registration by 10/7:
USATF-NJ Members until 10/7:
After 10/7 & Race Day:
1.5 Mile Walk:
Online Registration:
Timing: Tristate Timing
USATF Certified/Sanctioned
NJ Grand Prix 500 Points
Water stops on course and at finish
Long sleeve t-shirts available to preregistered runners, others while
supplies last. Goodie bag for
Pre-race packet pick up:
Summit Running Company
355 Springfield Ave
Summit, NJ
Friday, 10/24 - 12:00-7:00
Saturday, 10/25 - 10:00-3:00
Sunday, October 26, 2014
Memorial Field, Berkeley Heights, NJ
Race Schedule:
8:30AM - Packet Pick-up & Registration
9:30AM – Race Start
9:45AM – 1.5 Mile Walk
10:30AM– Awards
Race Awards:
1st, 2nd & 3rd Overall Male/Female
1st, 2nd & 3rd in 10 & under, 11-14, 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 4549,50-54, 55-59, 60-69, 70-80, 80+
This will be a festive, family -friendly event with food and beverages, live music,
awards, goodie bags for participants and activities such as a Teddy Bear Clinic
and face painting for the kids and “Ask the Medical Expert.”
All proceeds of the race will support the Summit Medical Group Foundation’s
initiatives, including fostering health and wellness in our community, developing
the next generation of medical professionals, and medical research. Find out more
Race Contacts:
Lauren Bland- 908-673-7323 [email protected]
Chris Schiffer- 908-821-9764 [email protected]
Can’t participate? Please consider making a donation!
Mail check and form to: Summit Medical Group Foundation, 150 Floral Ave, New Providence, NJ 07974
Make checks payable to: Summit Medical Group Foundation
Last Name ______________________________________ First Name _______________________________________
Email _____________________________________________________________5K _________ 1.5 Mile Walk ________
Street Address _________________________________ City ________________________ State ___ Zip __________
DOB: ___________ Age on Race Day:_____ Sex: M F USATF #____________________T-Shirt – AS AM AL AXL YM YL
Release and Waiver of Liability: I, ________________________(print name) acknowledge that participation in the 5K Fun Run and 1K Walk involves
a risk of injury, including bodily injury, and I assume all risks associated with running this event including but not limited to falls, contact with other
participants, the effect of the weather, traffic and the conditions of the course, 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, myself and anyone entitled to act on my behalf, waive and release the
Summit Medical Group Foundation, AC Race management, Race Director, all race volunteers and all sponsors, their representatives, employees and
successors from any and all claims and liabilities of any kind arising out of my participation in this event or carelessness of the person named in this
waiver. If I am an employee of the Summit Medical Group or Summit Health Management, I acknowledge that my participation in the 5K Fun Run and
Walk is completely voluntary and does not constitute part of my work-related duties. I grant to all of the foregoing permission to use any photographs,
motion pictures, recordings, videos or any other record of this event for legitimate purposes.
Signature (Parent or Guardian if Under 18)_________________________________________ Date_______________
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