Lewis County Hospital

Foundation
Spring Into Health
5K/10K & Fun Run
Saturday, April 22, 2017
Lewis County General Hospital
REGISTRATION INFORMATION * PLEASE CONSIDER ONLINE REGISTRATION AT RUNSIGNUP.COM *

5K Walk/Run -$25 Includes race, raffle entry, and a T-shirt to those registered by April 14th.
Registration fee is $30 on race day.
5K/10K Medals will be given to the 1st place walker/runner in each age/gender category.
Fun Run-Free for children ages 3-10.
Registration Check-In from 8am until 9am. (Dialysis Lobby of LCGH)
The 10K Race starts at 9:00 am. The 5K Race starts at 9:30 am.
The Fun Run starts at 9:45 am. Children need to be checked in by 9:30 am.
Please note: Supervision of children will not be provided during the 5K event.

ENTRY FORM
Name:_____________________________________________ Address: __________________________________
State/Zip: _________________________________________ Phone: ___________________________________
Email: _____________________________________________ Gender: (Circle One) Male Female
Age Group: (Circle One): Under 10 11-20 21-30 31-40 41-50 51-60 61 & Over
5K Walk $25 Pre-Registration T-Shirt Size: S M L XL 2XL
5K Run $25 Pre-Registration T-Shirt Size: S M L XL 2XL
10K Run $25 Pre-Registration T-Shirt Size: S M L XL 2XL
Note: $30 Registration on the Day of Event, no shirt guaranteed
Fun Run (FREE)
Extra T-Shirt ($10) T-Shirt Size: S M L XL 2XL
Total Enclosed $ ___________________
Please make checks payable to: Lewis County Hospital Foundation and mail completed
forms to: 7785 North State Street, Lowville, NY 13367. For additional information, please
contact the Hospital Foundation at 315-376-5110 or jrhubart@lcgh.net.

Note: All 5K/10K and Fun Run participants must complete and sign and an acknowledgement
of risk and accident waiver and release of liability on the back of this form prior to the race.
 Lewis County Hospital
Foundation
Spring Into Health
5K/10K & Fun Run
Saturday, April 22, 2017
Lewis County General Hospital

ACKNOWLEDGEMENT OF RISK ACCIDENT WAIVER AND RELEASE OF LIABILITY

In consideration of you accepting this entry, I, the participant, intending to be legally bound and hereby
waive or release any and all right and claims for damages or injuries that I may have against the Event Direc-
tor, RunSignup.com, and all of their agents assisting with the event, sponsors and their representatives and
employees for any and all injuries to me or my personal property. This release includes all injuries and/or
damages suffered by me before, during or after the event. I recognize, intend and understand that this re-
lease is binding on my heirs, executors, administrators, or assignees. I also authorize the use of photographs
or videos that include my image for promotional, informational, or other reasons deemed to be in the best
interest of the event. I certify as a material condition to my being permitted to enter this race that I am physi-
cally fit and sufficiently trained for the completion of this event and that my physical condition has been veri-
fied by a licensed Medical Doctor. By submitting this entry, I acknowledge (or a parent or adult guardian for
all children under 18 years) having read and agreed to the above waiver. I HAVE READ THE ABOVE OR I AC-
KNOWLEDGE, IF VERIFIED THAT I HAVE HAD THIS DOCUMENT READ TO ME AT MY REQUEST AND BY SIGN-
ING IT I AGREE IT IS MY INTENTION TO PARTICIPATE IN THE INDICATED ACTIVITY AND I UNDERSTAND AND
ACCEPT ALL THE RISKS INVOLVED.

DATE: ____________________

LOCATION: Lewis County General Hospital

PARTICIPANTS FULL NAME (print)______________________________________________________

DATE OF BIRTH: __________________________________

ADDRESS: _________________________________________________________________________

PARTICIPANT SIGNATURE: ____________________________________________________________

(Parent/Guardian Signature if participant is under 18 years of age.)