Registration Form

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GOTR OFFICE USE ONLY

Registration Form

Date entered

Paid

l Cash l Check l CC

Bib Number

REGISTER ONLINE at www.5k.gotrchicago.org or return the completed application with your check payable to Girls on the Run-Chicago. Registration forms must be received 14 days prior to your event date. Each runner must complete a separate form. You must be registered in order to participate in the 5k. THIS FORM DOES NOT NEED TO BE COMPLETED FOR GIRLS WHO ARE CURRENTLY PARTICIPATING IN THE SPRING PROGRAM.

Please check the event you will be participating in:

First Name: _____________________________________ Last Name: _______________________________ Gender:

l Female l Male

Birthday: ____ /____ /________

Email: _____________________________________________________ Phone: ( _____ ) ________________

l

May 15, 2016

Chicagoland Speedway Joliet, IL

l May 22, 2016 College of Lake County Grayslake, IL

l June 4, 2016 Grant Park Chicago, IL

Address: _________________________________________________________________________________ City: __________________________________________ State: _________________ Zip: _______________ SELECT SHIRT SIZE: l YXS l YM l YL/Adult XS

l Adult S l Adult M l Adult L l Adult XL l Adult XXL

SELECT RACE/ETHNIC ORIGIN:

l Caucasian l African-American

l Latino

l Asian

l Other

l Prefer not to answer

Emergency Contact Name ____________________________________________________________________ Emergency Contact Phone: ( _____ ) ________________ Emergency Contact Relation: _________________ Each school or program site will be assigned to a starting group and time. If you plan to run with a girl who is in a Girls on the Run program this spring, you must answer the question below. Please indicate the school or site that you plan to run with: __________________________________________ FEES: Adults (age 15 and older):

Youth (ages 7-14)

Li’l Sparks (ages 2-6)

l $40 in advance l $50 on 5k day

l $30 in advance l $35 on 5k day

l $15 in advance l $20 on 5k day

Paper forms received after the deadline (14 days prior to your event date) will not be processed. Will you support GOTRC with a $5.00 donation?

l Yes l No

Total Amount Enclosed $_________ Entrant’s Signature __________________________________________________________________________ Guardian’s Signature _________________________________________________________________________ Parents or guardians sign if the entrant is under 18 years of age. This is to certify that my son/daughter has my permission to participate in the Girls on the Run 5k, is in good physical condition and that the event officials have my permission to authorize medical treatment if necessary.

Registration form must be received 14 days before your event date. Mail to: Girls on the Run-Chicago 1415 N. Dayton St., Suite 112 Chicago, IL 60642 Waiver: In consideration of my participation in the Girls on the Run 5k and/or any pre- or post-event activities (collectively “the Event”) I, for myself, my heirs, administrators, personal representatives, successors and assigns, waive any and all rights, claims and causes of action I may have against any Race Organizer that may arise as a result of my participation in the Event. For these purposes, a “Race Organizer” is any one or more of the following: Girls on the Run-Chicago; the Chicago Park District, members of the Chicago Park District Board, the officers, agents, and employees of the Chicago Park District, individually and collectively; the Department of Cultural Affairs and Special Events; the College of Lake County (Grayslake); DCASE; the Chicagoland Speedway Joliet, IL; Lakeshore Athletic Services; Chicago Event Management and their affiliates; all governmental agencies representing the territory in which the Event will be held; all sponsors, agents, vendors, and contractors of or for the Event; medical service providers; and the officers, directors, employees, representatives, successors and assigns of each of the foregoing. I further attest and verify that I am physically fit and have sufficiently trained for the Event and that, if appropriate, my physical fitness to participate in the event has been verified by a licensed medical doctor. I expressly assume all known and unknown risks associated with the Event, including but not limited to damage to my property, injury; accidents; the effects of weather, and natural and manmade obstacles. I hereby agree to indemnify all Race Organizers for all claims and losses which may be brought against any one or more of them by anyone claiming to have be injured or otherwise to have suffered loss or damage as a result of my participation in the Event. I further grant full permission to any and all of the foregoing to store, use and/or reproduce my image or likeness by any audio and/or visual recording technique now in existence or hereafter invented, for any legitimate purpose, including commercial sales and marketing purposes.