June 1, 2013 9AM @ Lance Corporal Patrick B. Kenny Memorial Field 5K Run/Walk Registration Form • I plan on participating in the (check one): • _____5K Run _____5K Walk _____Neither (Please accept my donation) • Name:_______________________________________________________________________________________ • (please print clearly) • Address:_____________________________________________________________________________________ • City:______________________________________ State:_______________________________________ • Zip Code:__________________________________ Phone:_______________________________________ • Age:______________________________________ Gender (circle one): Male Female • (On June 1, 2013) • *T-Shirt Size (circle one): Youth S Youth M Youth L Small Medium Large XL XXL XXXL • Amount enclosed:____________________ ($20 if postmarked or delivered on or before May 17, 2013) • ($25 if postmarked or delivered on or after May 18, 2013) • Donation (if applicable):______________ **mail in registration forms will not be accepted after Tuesday, May 28, 2013.** • WAVIER: In consideration for the acceptance of my entry, I, for myself, my heirs, executors and assigns, do hereby waive, release and forever discharge the LCpl Patrick B. Kenny Memorial 5K Run/Walk, the LCpl Patrick B. Kenny Memorial Fund, the Semper Fi Fund, the towns of Emsworth and Ben Avon, Pennsylvania, their representatives, successors and assignees, and all sponsors, officials, and volunteers for all liability, loss, damage, claim or cause of action, foreseen or unforeseen, arising from or growing out of my association with or participation in the 5K run/walk held on Saturday, June 1, 2013 in Emsworth and Ben Avon, Pennsylvania. I understand and agree that there are potential risks associated with the 5K run/walk. I attest and verify that I have no medical history or condition that would preclude my participation in the 5K run/walk. Iam, therefore, voluntarily entering and participating in the 5K run/walk at my own risk and will assume all risks associated with participating in this run/walk. I also release any photos and recordings that may involve myself participating in this run/walk. • I certify that I have read and understand all the terms and conditions of this release and intend to be legally bound thereby. • If participant is under 18 years of age at the time of this registration: I, as parents or legal guardians of participant, have fully read, understood and consented to the terms and conditions of this release and authorize their participation by my signature below. • ____________________________________________________________________________________________ • Signature: • ____________________________________________________________________________________________ • Parent/Guardian Signature if under 18: • ____________________________________________________________________________________________ • Date: • Please make checks payable to: LCpl Patrick B. Kenny Memorial Fund and mail check and registration form to: • LCpl Patrick B. Kenny Memorial Fund, 176 Center Avenue, Pittsburgh, PA 15202. • *Sizes guaranteed for pre-race day registration. Shirts are for runners and walkers only. • Registration fees are non-refundable. • The Avonworth School District does not sponsor or sanction this program/event/activity. • The event will take place rain or shine. • Questions? Please email PBKfund@yahoo.com.