2015_SPA_DFD_RegFlier2 355.4 KB

RELEASE & ASSUMPTION OF RISK
As a participant, I agree to defend, protect, indemnify
and hold harmless the Dash for Dan organization and
St. Peter the Apostle against and from all claims arising
from the negligence or fault of Dash for Dan or
St. Peter the Apostle or any of its agents, family
members, officers, volunteers, helpers, partners,
organizational members or associates which arise out of
the participating in any and all activities connected with
or associated with Dash for Dan or St. Peter the Apostle.
Additionally, the Dash for Dan organization agrees to
protect, defend, hold harmless and fully indemnify
St. Peter the Apostle for any claim or cause of action
whatsoever arising as a result of participating in the
Dash for Dan 5K Event that is brought against
St. Peter the Apostle by Dash for Dan committee
members or their family members whether such
claim arises from the alleged negligence of St. Peter
the Apostle, its employees or agents or Dash for Dan
members negligence. If any portion of this agreement is
held invalid, it is agreed that the balance thereof, shall
continue in full legal force and effect.
I know that running or walking a road race is a
potentially hazardous activity. I should not enter and
run/walk unless I am medically able and properly
trained. I assume all risks associated with running in this
event including, but not limited to: falls, contact with
other participants, the effects of weather, including
heat and/or humidity, traffic, and the conditions of the
road/path. I have read and fully understand the above
waiver.
I further grant permission to use any photographs,
motion pictures, recordings or any other records of this
event for any legitimate reason.
I have carefully read this Release and Assumption of
Risk and fully understand its contents. I voluntarily
sign it and realize that this will bind me, my heirs, and
personal representatives.
(NOTE: parent or guardian must sign if participant is
less than 18 years of age. For “family registration” all
participating adults must sign, participating parent
signature will additionally serve as a Release and
Assumption of Risk for family participants less than
18 years of age)
a
5K
event
in memory of
Daniel Christophe, Jr.
Saturday, June 6, 2015
Registration: 8:00 am | Start Time: 9:00 am
Breakfast will immediately follow the race
DASH FOR DAN
PO Box 952 | Itasca, Illinois 60143
Telephone: 630.414.0825
Web site: dash4dan.com | E-mail Address: dash4dan@gmail.com
Date__________________________
Signature:____________________________________________
Signature:____________________________________________
Signature:____________________________________________
GENERAL INFORMATION
Signature:____________________________________________
If you are unable to participate in the event but would like to
sponsor a participant or make a donation, please complete
the registration form accordingly.
Signature::___________________________________________
Registration will be accepted on race day, but t-shirt and
care package cannot be guaranteed.
Signature:____________________________________________
REGISTRATION FORM
Deadline: May 15, 2015
Groups of 6+ should contact event chairs
for pricing/registration information
a
5K
event
in memory of
Daniel Christophe, Jr.
Saturday, June 6, 2015
Registration: 8:00 am | Start Time: 9:00 am
Breakfast will immediately follow the race
ST. PETER THE APOSTLE
PO Box 952 | Itasca, Illinois 60143
Telephone: 630.414.0825
Web site: dash4dan.com | E-mail Address: dash4dan@gmail.com
The seventh annual “Dash for Dan” 5K event
will take place on Saturday, June 6, 2015 in
Itasca, Illinois. “Dash for Dan” is being held in
memory of Daniel Christophe, Jr., an Itasca
youth whose life was cut short by a tragic
motorcycle accident on the afternoon of
April 17, 2007.
Although wearing a helmet and following the rules of the road,
while riding his motorcyle Dan fell victim to a tragic accident
with another driver. The impact of the collision caused Dan to
suffer injuries too severe to overcome.
At the time of the accident, Dan was an accounting major at
Northern Illinois University. He was a graduate of Lake Park High
School (class of 2004) and St. Peter the Apostle Catholic School
(class of 2000).
St. Peter the Apostle is honored to sponsor “Dash for Dan” in
memory of this cherished alum. In recognition of the Christophe
family’s dedication to Catholic education, proceeds from this
event will go to help fund a memorial scholarship established in
Dan’s name.
We hope you will join in supporting this seventh “Dash for Dan”
and help to continue Dan Christophe’s legacy within the
community.
GENERAL INFORMATION
Proceeds from this event will go to fund two (2) $1,000
scholarships (one to a Lake Park High School senior and one to
high school senior who belongs to St. Peter the Apostle Parish.
In addition, a donation will be made to St. Peter the Apostle
and to Camp Kaseem (a camp for children whose parent(s)
have cancer).
The concealment and carrying of firearms is prohibited at this event under law.
Name_____________________________________________
Address___________________________________________
City_____________________ State_ _____Zip _ __________
Telephone Number__________________________________
E-mail ____________________________________________
Entry fee includes t-shirt, care package and breakfast.
r Individual Adult (15 and up)
r Individual Youth (14 and under)
r Family Registration (up to 4 people)
___additional family members @ $15
r I would like to make a donation
$ 30
$ 20
$ 80
$___________
$___________
TOTAL AMOUNT ENCLOSED
$___________
Runners clubs receive a special rate. Please contact
Judy Metoryer for more details at dash4dan@gmail.com
or 630.414.0825.
Please make payment by CASH or CHECK payable to
“Dash for Dan” and submit payment to:
Dash for Dan
P.O. Box 952
Itasca, IL 60143
PARTICIPANT/FAMILY LAST NAME______________________
PARTICIPANT NAME(S) 1_____________________________ (as of 06/06/15) AGE SEX
_____
M F
2_____________________________ _____
M F
3_____________________________ _____
M F
4_____________________________ _____
M F
5_____________________________ _____
M F
T-shirt size (if registering as family, please indicate number of
t-shirts per size)
Adult:
Youth:
_ ____ S _____ M _____ L _____ XL _____2X
_____ S _____ M _____ L
RELEASE AND ASSUMPTION OF RISK ON REVERSE HEREOF
MUST BE SIGNED WITH APPLICATION
Prizes will be awarded in several adult and child
categories. One (1) cash prize will be awarded to
the top runner who comes in first place.