The PINWHEEL PROMISE Child abuse awareness 5k Family Walk and fun day “April is a time to celebrate the important role that communities play in protecting children” April 25th, 2015 Registration begins at 8:00 AM Kick-off for Awareness 9:00 AM Walk to follow Children’s activities from 9-noon Vendors on-site from 9-noon LOCATION: Franklin Parks and Recreation Center 396 Branigin Blvd. Franklin, IN 46131 Registration held at large shelter house, located just down the hill from the pool. Walk will begin and finish at pool parking lot. REGISTRATION: To qualify for Early Registration, please mail/bring completed Registration form and entry fee to: 520 Tracy Road Whiteland, IN 46184 Attn: Rachelle Steele. Checks may be made payable to The Children’s Bureau. Registrations will also be accepted the day of the event beginning at 8AM. COST: Advance registration: Race-Day registration: $15.00 per adult, includes T-Shirt $10.00 per child, includes T-Shirt $40.00 per family, includes up to 4 T-Shirts (Additional shirts may be purchased for $8.00 each) Pricing remains the same. However, T-Shirt supply will be limited for registrations received after April 14th. Amenities: Free refreshments and snacks will be available to participants! Coupons, prizes, and give-aways!! Fun and engaging activities for children!!! Informational booths, vendors and activities for families and the community!!!! CONTACT: Coordinators: Rachelle Steele, 535-3326 and Teddi Adams, 340-9568 Email: rsteele@childrensbureau.org and Teddi.Adams@dcs.in.gov REGISTRATION FORM The pinwheel promise Child abuse awareness 5k family walk Please complete one form per participant/family. Forms, along with entry fee, should be mailed or brought to: 520 Tracy Road Whiteland, IN 46184 Attn: Rachelle Steele. Checks may be made payable to The Children’s Bureau. Please print NAME: NAME: NAME: NAME: NAME: Address: ___________________________ ___________________________ ______ First Last Age ___________________________ ___________________________ ______ First Last Age ___________________________ ___________________________ ______ First Last Age ___________________________ ___________________________ ______ First Last Age ___________________________ ___________________________ ______ First Last Age ___________________________ Street ___________________________ City ________ ____________ State Zip Code Contact Phone Number: _____________________________ Contact Email: _____________________________ T-Shirt Size(s): Youth Size(s): ______________ Adult Size(s): ______________ ( ) In lieu of T-Shirt(s), I/we elect to donate full registration fee to Prevent Child Abuse. COST: Advance registration: Race-Day registration: $15.00 per adult, includes T-Shirt $10.00 per child, includes T-Shirt $40.00 per family, includes up to 4 T-Shirts (Additional shirts may be purchased for $8.00 each) Pricing remains the same. However, T-Shirt supply will be limited. Waiver and Release: I know that my participation in an organized running or walking event, regardless of distance, includes an element of risk. I understand that I should not enter and participate in “Child Abuse Awareness 5K” (hereinafter “this event”) on April 25th, 2015 unless I am medically able and properly trained. I agree to abide by any decision of an event official, relative to my ability to compete this event safely, and I further agree that event officials may authorize necessary emergency treatment for me. I also understand that both vehicle traffic and spectators may be present along the course, and I assume the risk of participating under such conditions. I further assume any and all other risks associated with my participation in the event, including but not limited to, illness, traveling to and from the event, falls, contact with spectators or other participants, the effects of the weather (including temperature extremes and humidity), and the surface condition of the 5K route, roads, bike trail, and sidewalks, all such risks being under-stood and appreciated by me. By signing this waiver, I am agreeing to WAIVE and RELEASE any and all rights and claims for negligence, injury, damages or losses that I may incur against all participating agencies involved in the planning, coordinating, sponsoring or holding this event. Having read this waiver and knowing these facts, and in consideration of the acceptance of my entry, I hereby for myself, my heirs, executors, administrators, or anyone else who might claim on my behalf, covenant not to sue and I waive, release, and discharge all subsidiaries, affiliates, assigns, representatives, and successors of the forgoing: City of Franklin, Franklin Parks & Recreation Department, contractors, employees, all participating agencies involved in the planning, coordinating, sponsoring or holding this event and any other personnel in any way assisting or connected with this event from any and all claims or liability of any kind or nature whatsoever arising out of my participation in this event, even thought that liability may arise of negligence or carelessness on the part of the parties named in this waiver. I also understand and agree that any sponsor may subsequently use, for publicity or promotional purposes, my name and/or pictures of me participating in this event without liability or obligation to me. Entries cannot be accepted without a valid signature. Entries from minors will be accepted only with a parent’s or legal guardian’s signature. Signature of Participant Date ___________________________________ ___________________ Signature of Parent/ Legal guardian Date (for participants under 18) ___________________________________ ___________________