2nd Annual KHCPL RUDOLPH FAMILY FUN RUN REGISTRATION FORM

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1 2nd Annual KHCPL RUDOLPH FAMILY FUN RUN REGISTRATION FORM A 5k run/walk for all ages and abilities. 9 a.m., Saturday, Dec. 5, No rain/weather date. No refunds. For the schedule and all the details go to Dogs welcome. (Each must be current on vaccinations, well-controlled, and on a leash.) Please print. List information for only 1 participant on each registration form. PARTICIPANT INFORMATION First name Last name Male Female DOB (month/day/year) Age on race day ( ) Street address/po BOX City State ZIP Phone (daytime) Select one 5k run 5k walk T-SHIRT ORDER ADULT shirt size XS S M L XL 2XL** 3XL**

2 4XL** 5XL** ***2XL/3XL/4XL/5XL, add an additional $2 fee per shirt YOUTH shirt size XS(4-6) YS(6-8) YM(10-12) YL(14-16) YXL(18-20) (PLEASE NOTE: TO RECEIVE A T-SHIRT FOR THE RACE, YOU MUST REGISTER AND PAY BY NOV. 19.) REGISTRATION FEES EARLY BIRD REGISTRATION FOR AN INDIVIDUAL: $20 registration if you sign up by Nov. 15 Individual registration: $25 from Nov. 16 to day-of registration on Dec. 5 EARLY BIRD REGISTRATION FOR A FAMILY OF 3 OR MORE: $50 registration if you sign up by Nov. 15 Family of 3 or more registration: $60 from Nov. 16 to day-of registration on Dec. 5 CHOOSE ONE OF THREE EASY WAYS TO REGISTER 1. Online through Eventbrite at 2. In person at KHCPL Main, South, or Russiaville. 3. Download the forms below, slip them into an envelope, along with a check made out to KHCPL, and mail to: Lisa Fipps, KHCPL Main, 220 N. Union St., Kokomo, IN (Please note: There will be a processing fee to register online.)

3 ***Make checks payable to Kokomo-Howard County Public Library. Please write FUN RUN on the memo line. If paying the registration fee for more than one person, please note the names here:

4 DEC. 5 RUDOLPH FAMILY FUN RUN SCHEDULE Day-of registration begins at 7:30 a.m. Those who have registered before the event can pick up packet, including shirt and bib number, between 7:30 a.m. and 8:45 a.m., inside the library. Race will start at 9 a.m. After the race, participants can nosh on healthy snacks. Guest speaker. Information TBA. 9:45 a.m.: Guest speaker and then door prize drawing. We have 10 door prizes, including Garmin Forerunners! Must be present to win. Then the trophies will be awarded. Trophies, sponsored by Salin Bank, will be awarded to the top overall male and female finishers in the run and in the walk, and to the top male and female runners in each of the following age groups: 0-12; 13-19; 20-29; 30-39; 40-49; 50-59; 60+ and one overall walker per age category. Results will be posted at Photos will be posted on the KHCPL Facebook page. WATCH AND OUR FACEBOOK PAGE FOR UPDATES!!!

5 KHCPL RUDOLPH FAMILY FUN RUN WAIVER AND RELEASE The individual signing below, including electronically if submitted online, (the Participant ) submits this Waiver and Release ("Waiver and Release") to the Kokomo Howard County Public Library ( Library ) as (a) a runner or volunteer for the Library 5K (the Event ); (b) a parent, legal guardian or attorney-in-fact of a runner or volunteer for the Event; or (c) a runner or volunteer for the Event AND a parent, legal guardian or attorney-in-fact of a runner or volunteer for the Event. This Waiver and Release applies to and is binding upon the Participant submitting this Waiver and Release in each applicable capacity listed above. Participant knows that running and/or walking a road race and/or participating in the training for a road race, including, without limitation, the Event and any event sponsored by the Library is a potentially hazardous activity. Participant understands that an individual should not participate in the Event unless medically able and sufficiently trained to do so. Participant acknowledges that Participant has voluntarily agreed to participate as a runner or volunteer for the Event. Participant agrees that Participant and/or Participant s heirs, guardians, legal representatives, successors, distributees, and assignees will not make a claim against, sue, attach the property of, or prosecute the Library or any of its affiliated organizations, officers, employees, volunteers, staff, Board of Trustees, agents and other representatives of the foregoing, and any successors or assigns of the foregoing for any losses, injury, death or property damage occurring to Participant as a result of participation (either directly or indirectly) in any of the activities related to training and running in the Event whether caused by negligence of the Library, or otherwise. Participant irrevocably grants a perpetual, royalty-free license to the Library to use Participant s name, image and/or likeness for the purpose of promoting the Library in any manner worldwide - either in print material, radio or television broadcast or online, in any manner whether presently in existence or hereinafter developed. To the extent this Waiver and Release is not enforceable with respect to the minor or other individual for whom Participant is the parent, legal guardian or attorney-in-fact, Participant agrees to indemnify the Library or any of its affiliated organizations, officers, employees, volunteers, staff, Board of Trustees, agents and other representatives of the foregoing, and any successors or assigns of the foregoing, from any and all damages, claims or liability they may suffer or incur as a result of said minor or other individual's participation in the Event, including but not limited to court costs and attorney fees. Any participation in the Event is expressly conditioned upon Participant's agreement to this Waiver and Release and by signing or electronically submitting this entry form Participant understands and agrees with all terms of this Waiver and Release. Participant has read, understood, and accepts the agreement above. Participant's submission of this form shall act as legal signature.

6 Participant signature: Date: Parent /Guardian Signature: Date:

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