Walk/Run for a Healthier Community

5K Walk/Run & Super Hero Challenge

Lewis County General Hospital Lobby

Saturday, May 9th

Registration Fee:
5K $25.00-includes water bottle, raffles and medals.
Super Hero Challenge: $10.00-includes water bottle, raffles & participation ribbon. For children 3-10.
5K Awards: Medals for 1st place runners in each age/sex category.
Race Information: Registration Check-In begins at 8:00 am. The 5K Race starts at 9:00.am The Super
Hero Challenge starts at 10:00 am. All races begin and end in the Childrens Clinic Parking Lot on
the Hospital Campus.
Waiver: All participants must sign an acknowledgement of risk and accident waiver and release of
liability prior to the race (waiver on back of this page).
Contact Information: For additional information, please contact Julie Hanno at 376-5200 or
JoAnne Rhubart at 376-5110.
Entry Form
Name: _____________________________________________________________________________
Address: ___________________________________________________________________________
State/Zip: __________________________________________________________________________
Phone: _______________________________ Email: ______________________________________
Sex: (please check one)
Age Group: (please check one)

Male

Female

Event (please check one)

5K Walk
5K Run
Super Hero Challenge

Under 20 21 to 30 31 to 40 41 to 50 Over 50
$__________________
$__________________
$ __________________

Please make checks payable to:

Lewis County Hospital Foundation
7785 North State Street
Lowville, NY 13367

Total Enclosed $_____________________

Sponsored by

Lewis County Public Health

ACKNOWLEDGEMENT OF RISK ACCIDENT WAIVER AND RELEASE OF LIABILITY

I, ______________________________________ (Participant) acknowledge that I have voluntarily

applied to participate in the Lewis County Hospital Foundation Walk/Run and acknowledge as follows:
I fully understand and acknowledge that there are inherent risks and dangers in my participation the above
activities and my participation in said activities and use of any equipment or materials related to such activities may result in my injury, illness or death and damage to or loss of my personal property. I understand
other participants, accidents, forces of nature or other causes may cause these risk and dangers and hereby
fully acknowledge and accept these risk and dangers. I am in good health and I am able to participate in any
strenuous physical activity associated therewith. I herewith release, forever discharge and waive any right
of recovery or subrogation against Lewis County Hospital Foundations activities, its officers, directors, employees and volunteers from any and all liability whatsoever for any illness or injury, including death or damage to or loss of my personal property that I may sustain while I am participating in this program. This shall
be binding on my heirs, successors, assigns, administrators and executors and executors. Any claims or disputes arising out of my participation in the activity shall first be submitted to arbitration and/or be venued in
the Supreme Court of the State of New York of the County of Lewis.
I HAVE READ THE ABOVE OR I ACKNOWLEDGE, IF VERIFIED THAT I HAVE HAD THIS DOCUMENT READ TO ME
AT MY REQUEST AND BY SIGNING IT I AGREE IT IS MY INTENTION TO PARTICIPATE IN THE INDICATED ACTIVITY AND I UNDERSTAND AN ACCEPT ALL THE RISKS INVOLVED.
DATE: ____________________
LOCATION: ________________________________________________________________________
PARTICIPANTS FULL NAME (print)_____________________________________________________
DATE OF BIRTH: __________________________________
ADDRESS: _________________________________________________________________________
PARTICIPANT SIGNATURE: _________________________________________________________
PARENT OF PARTICIPANTS UNDER AGE 18 SIGNATURE

5K Walk/Run Route