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Entry Form - Presence Our Lady of the Resurrection Medical Center Fall into Fitness 5K Run/Walk

First Name ____________________________
Last Name ____________________________

Address ____________________________________________________________________

City, State Zip _______________________________________________________________

Birthday ________________________
Age on Race Date ____________________________

E-mail Address ______________________________________________________________

Please Check: __ Male __ Female

Shirt size: __ S __ M __ L __ XL __ XXL

WAIVER: I agree to abide by the rules and the decision of any event official relative to my (my child's) ability to safely complete the event. I assume all risks associated with my (my child's) participation in the Fall into Fitness 5K Run/Walk and other related events, including, but not limited to, falls, contact with other participants, the effect of the weather, traffic, road conditions, all such risks to myself (my child) being known and appreciated by me. Having read this waiver, and knowing these facts, and in consideration of the acceptance of my (my child's) entry, I for myself or my child and anyone entitled to act on our behalf, waive and release Presence Our Lady of the Resurrection Medical Center, Resurrection Health Care, Chicago Park District, Jim Brimm & Associates, race-day volunteers, all event sponsors, their representatives and successors from all claims or liabilities of any kind arising from my (my child's) participation in this event. The event will proceed rain or shine. No Refunds.

For participants under 18, a parent or guardian's signature is required.

Participant's Signature ___________________________________
Date __________________

AMOUNT ENCLOSED: PRE-RACE RACE DAY
Adults (ages 18+) ___ $20 ___ $25
Youth (ages 6-17, 5 and under free) ___ $10 ___ $15
Seniors (ages 60+) ___ $10 ___ $15
Family (up to five members) ___ $45 ___ $55
Children 5 and under ___ Free ___ Free