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: https://runsignup.com/smgf5k $25 $22 $30 $10 Timing: Tristate Timing Course: USATF Certified/Sanctioned NJ Grand Prix 500 Points Water stops on course and at finish Amenities: Long sleeve t-shirts available to preregistered runners, others while supplies last. Goodie bag for participants. 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 at: www.smg-foundation.org Race Contacts: Lauren Bland- 908-673-7323 lbland@smgnj.com Chris Schiffer- 908-821-9764 cschiffer@aepg.com Can’t participate? Please consider making a donation! https://runsignup.com/smgf5k 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_______________