Children's Miracle Network Telethon - Geisinger Health System

Children’s Miracle Network
5K Run & Walk
Geisinger Medical Center, Knapper Clinic
Danville, PA
Saturday, June 5th, 2010
5:00 P.M.
REGISTRATION: $15 if received before May 28th, $20 after and on race day. Registration will
open at 4:00 PM. T-Shirts will be given to all runners. Those collecting $50 or
more in sponsors (not including the registration fee) will receive a Children’s
Miracle Network cool gear water bottle. Use the back of this form to collect
pledges.
COURSE:
Out and back 5K course of rolling hills. Walkers may choose a 1 mile course or complete the
5K course. Water will be available along the course.
AGE CATEGORIES & AWARDS FOR 5K PARTICIPANTS:
Plaques will be awarded to the Top fundraising individual and Top fundraising group
Large Trophies to Fastest Overall Male and Female Winners
Large Trophies to Overall Male and Female Masters
Trophies will also be awarded to the top 3 finishers in each of the following age groups:
- 14 & under, 15-19, 20-29, 30-39, 40-49, 50-59, 60+
**Door prizes will also be awarded at the awards ceremony**
*****For more information contact Children’s Miracle Network at 271-6188 or e-mail btharp@geisinger.edu*****
Charitable organizations that solicit contributions are required by the Commonwealth of Pennsylvania to provide the following statement: “A copy of the official registration and financial information may be obtained
from the Pennsylvania Department of State by calling toll free within Pennsylvania, 1-800-732-0999. Registration does not imply endorsement”
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ENTRY FORM
Name:___________________________________ Age:_______ Gender: M / F
Street Address:_________________________________
City: __________________________________________State:______ Zip Code:__________
T-Shirt Size: M L XL Event: 5K Walk 5K Run 1 Mile Walk
Name of Fundraising Group (If applicable): _________________________________________
Emergency Contact:_______________________________ Phone # ______________________
In consideration of permission for the undersigned Participant(s) to participate in the Miracles 5K run/walk. Participant(s), intending to be legally bound hereby, hereby agree for Participant(s) and
for Participant(s) heirs, executors, administrators and assigns, that Participant(s) will and hereby release and forever discharges Geisinger Health System Foundation, its affiliated corporations, and
all other persons, associations and corporations, both known and unknown, and their respective agents, servants, employees, board of directors, members, heirs, executors, administrators, assigns
and insurers (hereinafter called "Grantors") from all manner of claims, actions, or causes of action which Participant(s) now have or which Participant(s) or Participant(s) heirs, executors,
administrators, assigns hereafter can, shall or may have because of bodily injury, including death, or damage or loss to property which Participant(s) may suffer while participating in the above
activity, whether the said injury, including death, or damages may be due to a negligent act or omission of the said Grantors, or otherwise. It is acknowledged that the risks of injury or damages
may be inherent in this activity and that Participant(s) accept full responsibility for Participant(s) own voluntary decision to participate in the activity and Participant(s) fully assume the risks of injury
and damages from both known and unknown causes, both obvious and hidden conditions and conditions for which warnings were or were not specifically provided. It is additionally understood that
Participant(s), who may in any fashion be employed by Geisinger Health System Foundation, Geisinger Clinic, Geisinger Medical Center, Geisinger Wyoming Valley Medical Center or any one of the
affiliated Geisinger Corporations not herein noted specifically, is (are) voluntarily entering into the aforementioned activities outside of the course and scope of their employment and will not under
any circumstances, should injury occur during these activities, qualify or be entitled to Workmen's Compensation or any other specific Compensation or benefit that may be applicable to injuries that
may occur during the course and scope of employment, for any injuries suffered from their participation in the above noted activities.
Participant’s Signature:
DATE:
Signature of Parent or Guardian (If under 18):
Send completed entry to: Children’s Miracle Network, 5K Walk/Run, 100 N. Academy Avenue,
Danville, PA 17822-5020
Make checks payable to: Geisinger Health System Foundation

Miracles 5K 2010
Pledge Collection Sheet
$50 or more receive a Children’s Miracle Network cool gear water bottle
All runners receive a free t-shirt
Name:
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Amount:
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If you are raising funds as part of an organization, please lit the organization below:
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