5KRun2015_Registration_Form

The Children’s House
RACE FOR HEALING 5K Run
DATE: Saturday, April 25, 2015
START TIME: 10 AM
Entry Fee/Registration : Registration fee is $20.00 (t-shirt guaranteed for pre-registrants). Pre-registration is
due April 10, 2015. Pre-registration can be done via mail. Make checks payable to: The Children’s House/CAC
Please send registration forms to The Children’s House P.O Box 335 Towanda, PA 18848. Registration can also be
completed on race day at 9-9:45 AM.
Course Description : Start
Pennsylvania Ave and W Frederick St - Head north
on 3rd St toward W Frederick St, Turn right onto W Frederick St , Turn left onto N Main St ,
Take the 1st right onto E Frederick St , Head south on N River St toward E Vanderbilt St, Turn
left onto S River St, Head south on S River St toward Ferry St, Take the 1st right onto Ferry St,
Continue onto Paine St , Head west on Paine St toward New St , Turn right onto N Elmira St,
Take the 1st right onto Wheelock Ave, Head northeast on Wheelock Ave toward 4th St,
Wheelock Ave turns left and becomes 4th St ,Turn left onto Longway St, Head west on Longway
St toward Pennsylvania Ave, Take the 1st right onto Pennsylvania Ave, Take the 2nd right onto
W Frederick St. to the Finish Line
Rac e Bac kground :
The Children’s House is a child-focused, facility-based program designed to provide services for child abuse victims.
The Children’s House provides a child friendly environment that reduces trauma to the child victim by providing a
place where children can feel safe. The services provided at the center are forensic interviews and medical exams to
child victims at no cost to the victim or families. Our ultimate goal is to be a place of healing for children victims of
abuse, with all the necessary services provided at no cost to the victim. The purpose of this event is to raise money in
support of The Children’s House as well as raise awareness in our community about child abuse.
Name:______________________________________ Phone:___________________________
Address:____________________________________ Email:___________________________
City:______________________________ State:____________ Zip:___________________
Date of Birth:___________________________ Age (on race day):_________________
Event: Run__________ Walk______________
Sex: Male_______________ Female_______________
T-shirt Size: Adult: S M L XL Child: S M L XL
Contact Person and Chairperson of this event is Danielle Gorman. Ms. Gorman is the Victim/Witness Coordinator
located in the District Attorney’s Office. If you or your business is interested in sponsoring the event, please contact
Ms. Gorman at gormand@bradfordco.org
Thank you for your sponsorship! It takes courage to care for children and valor to vanquish abuse. By
supporting the CAC, you are truly a hero for our community!
Please read and sign: in consideration of you accepting this entry, I, the undersigned intended to be legally bound for myself, my heirs, executors
and administrators, and waive and release any and all rights and claims for damages I may have against the CAC, Athens Borough, their officers and
executives, the town of Athens and any and all sponsors and their representatives, successors, and assigns for any and all injuries suffered by me in
said event. I attest and verify that I will participate in this event as a foot race entrant. A licensed medical doctor has verified that I am physically fit
and have significantly trained for the completion of this event and my physical condition. I hereby release photographer and his legal representatives
and assigns from all claims and liability relating to said photographs. If under 18, parent’s signature is required.
Signature:________________________________________________________________________________________
Date:_________________________________