Team Name_____________________________________________________  USATF Sponsored 5K RACE/WALK is out/back, flat road

Team Captain_____________________________ ______________________  race. We have online sign up at active.com and 

First Name______________________________________________________  www.KansasLyme.org  We will give awards for every 5 yr

Last Name ______________________________________________________ age group, Masters (not age graded), Overall winners.

Address________________________________________________________                                   CHIP TIMED!

City __________________________________ST ___ Zip _________________


Phone _________________________________Male _____Female ________

Email___________________________________________________________


(  ) Individual            (  ) Team             (  ) Sponsor


Click on TEAM and INDIVIDUAL FUNDRAISING! START YOUR TEAM TODAY!

www.active.com/donate/5KHOPE 



Teams or Families: Separate form for each participant, send together


T-shirt- with registration, first come, first served---limited supply



PLACE:   CrossPoint

ADDRESS: 1300 Harvest Road

                   Hays, Kansas 

                   Cell Phone--  **TICKBITE


SPONSORS: Bronze-$10                                       WELLNESS FAIR TABLES-email [email protected]   FREE IF bringing samples

                      Silver- $25                                        or sharing an activity with kids and families. Indoors, air conditioned, electricity.

                      Gold- $50

                      Platinum- $100



TEAM PRIZES! INDIVIDUAL PRIZES! FUN FAMILY ACTIVITIES!


Mail-in Registration (make checks payable to):

Kansas Tick-Borne Disease Advocates, Inc.

PO Box 442576

Lawrence, KS 66049

Questions? Call 785-248-3504 or email at [email protected]



Waiver: I know that participating in a road race is a potentially hazardous activity. I will not enter 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 participating including, but not limited to falls, contact with other participants, traffic, road conditions, or effect of weather. Having read this waiver, knowing these facts, and in consideration of your accepting my entry, I , for myself and anyone entitled to or who may claim to act on my behalf, waiver, release, discharge, and covenant not to sue the City of Lawrence, Lawrence Parks and Recreation, USATF, Kansas Tick-Borne Disease Advocates, Inc. (KSTBDA), Kansas Lyme Fighters, race sponsors, volunteers, vendors, independent contractors, Steve Riley, including their agents, employees, representatives, successors, assignees, or anyone acting on their behalf, from any and all claims or liabilities for death, personal injury or property damage of any kind or nature arising out of, or in the course of, my participation in this event, including claims or liabilities that may arise out of negligence or carelessness on the part of the persons named in this waiver. This release and waiver extends to all claims of any kind or nature whether foreseen or unforeseen, known, or unknown. The undersigned further grants full permission to Kansas Tick-Borne Disease Advocates, Inc. (KSTBDA), its race sponsors, and/ or agents authorized by them, to use any photographs, video tapes, motion picture recordings, or any other record of this event for any purpose including publicity. All applications for minors will be accepted only with the parents' signature and supervision of an adult. If a parent is signing on behalf of a minor, then the parent agrees to defend and indemnify all persons and entities listed in this Release & Waiver against any claim brought against them by the minor at any time, arising out of the minor's participation in this event. The race director reserves the right to shorten or cancel the event due to weather conditions with no refund. Thank you for your compassion!

Raising money for Kansans to gain equal access the Standard of Care according to www.ILADS.org


Deduction: We are a 501 c 3 nonprofit with the IRS. You may deduct 50% of your donation above the entry fee cost.

______________________________________________________________AGE if in timed event ______________________________

Signature of participant

______________________________________________________________Town you are representing__________________________

Date

______________________________________________________________

Parent or Guardian

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