DCF Community Awareness Day
Event Entry Form
(can be
duplicated)
Before 4/18 Race day
___5K Run/Walk $20 $25
___1 Mile Family Walk $8 $10
___Kids Fun Run free free
Make checks payable to: CT DCF Community Awareness Fund, 2 Buena Vista Rd., Branford, CT 06405
___Waived entry fee if enclosing check(s) for $100 or more to CT DCF Community Awareness Fund, 2 Buena Vista Rd., Branford, CT 06405
Last Name___________________________________ First Name___________________________________
Male_____ Female_____ DOB__________________ Age on race day _____ Physically challenged ___
Address______________________________________ City________________________State_________ Zip_______________
Phone____________________________
Email_________________________________________
Waiver: I know that running a road race is a potentially hazardous activity. I should not enter and run unless I am medically able and properly trained. I also know that although police protection will be provided, there will be traffic on the course route. I assume the risk of running in traffic. I agree to abide by any decision of any race official as to my ability to safely complete the run. I also assume any and all other risks associated with running this event, including but not limited to, falls, contact with other participants, effects of the weather, including high temperatures and/or humidity, extreme cold conditions, thunder and lightning, traffic and the conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf waive and release Department of Children and Families, City of Waterbury, State of CT, JB Sports, LLC, John Bysiewicz, race officials, volunteers, and all sponsors including their agents, employees, assigns or anyone acting on their behalf, from all claims or liabilities of any kind arising out of my participation in this event. I grant permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose. I know that dogs, bicycles, in-line skates, MP3 Players, and baby joggers are not allowed on the course. Application for minors under 18 will be accepted only with a parent's signature.
________________________________________________________________________
Athlete’s Signature (Parent’s signature if under 18)