5K Tye Dye Run Registration Form Saturday, January 3rd, 2015 Riverfront Park, Marysville Place: Yuba Levee @ 1st & ‘D’ Street, Marysville, CA Time: Registration 8- 8:45 AM, RUN starts @ 9 AM, WALK starts @ 9:30 AM Donation: * Run/Walk Pre-Registration $25 (postmarked by December 22nd) * Children 10 and under $10 (all pre-registered will receive a medal) * Race-Day Registration (or later after Dec. 22 nd) $25 no t-shirt ALL PROCEEDS GO TO HARMONY HEALTH Course: 5K will begin at 1 st & ‘D’ St. at the levee entrance behind the Bok Kai Temple, t h r o u g h R i v e r f r o n t P a r k & make a loop back to the starting point. Awards: All pre-registrations over the age of 10 will receive a Resolution Run T-Shirt; 5K awards will be presented to the overall male and female winners and to the top three finishers in each age division. FOR MORE INFORMATION, contact Harmony Health Family Resource Center at (530) 742-5049. To Pre- register (post marked by 12/21/14) return registration form along with a check for the appropriate amount made payable to: HARMONY HEALTH and mail to: Harmony Health, Attention: Tye Dye Run, 1908 North Beale Rd. Ste. D., Marysville, CA, 95901. ---------------------cut here------------------------cut here----------------cut here------------------PLEASE CIRCLE THE APPROPRIATE INFORMATION Circle Shirt Size: MALE S M L XL XXL FEMALE Age on Race Day ______ Print Name______ _ Date of Birth _____ _ Address_______ City________ AGE DIVISION (circle one): 5 & Under _ _ _ Email _______ _ State___ 6-9 ZIP___ 10-12 Phone _____ 13-17 18-39 _ 40-55 56+ RELEASE & WAIVER: I know that running is a potentially dangerous activity and that I should not enter this event unless I am medically able and properly trained, and that physical injury, illness and even death may result from risks inherent in this sport. I assume all risks associated with participatin g in this event, including, but not limited to falls, contact with other participants, the effects of the weather, including high heat and/or humidity, the conditions of the roads/trails and traff ic on the course. Having read this RELEASE AND WAIVER and in consideration of the acceptance of my entry, I , on behalf of myself and my representative and successors in interest, release and agree to indemnify, defend and hold harmless, even though any risks may arise out of negligence or carelessness on their part, Harmony Health Family Resource Center and all sponsors of this event and all agents, employees and representatives of the above, from all claims, suits, liabilities and actions. I also waive all rights I have under California Civil Code section 1542, which provides that a general release does not extend to claims which the releasing party does not know or suspect to exist. I grant permission for interested persons to photograph and record my participation in this event for publicity. I understand that bicycles, roller skates/blades, baby joggers, animals and radio headsets are not permitted. Signature___ Date (Must be signed by a parent or guardian if the participant is under the age of 18) Please feel free to duplicate this form. Visit our website @ www.myharmonyhealth.org