Allies Angel Ride

Saturday, May 31, 2014

All proceeds to benefit children and families of the Southern Tier of NY 5K Run/Walk and Bicycle Ride
Events begin and end at: Hickories Park; 359 Hickories Park Road, Pavilion 5, Owego, NY Event day registration and T-shirt pick-up starts at 8:00 a.m. Events begin at 10:00 a.m. Pre-Registration fee is $30, ending May 3rd; includes 2014 T-shirt, streamers, Allies Angels water bottle and meal ticket. Additional meal tickets are $10. Event Day Registration fee is $35: includes undated T-shirt (sizes may be limited), streamers, Allies Angels water bottle and meal ticket. Additional meal tickets are $10.
Full Name ________________________________________________________ ____ I am participating as an individual ____ I am part of a team; Team name:____________________________; Captain:______________________ Address _____________________________City__________________ State _________ Zip _________ Email_______________________________________Phone____________________________ Gender (please circle) M / F Birth Date_______________ Age on Event Day_______

Emergency Contact: Name ______________________________Phone _________________ ***To guarantee a T-shirt your pre-registration must be received prior to May 3rd, 2014*** Please Circle Adult Shirt Size: Please Circle Child Shirt Size: S S M M L L XL XL XXL 3XL

Pre-registration: 5K Run/Walk Fee ($30) ____

25 Mile Bicycle Ride Fee ($30) ____ 25 Mile Bicycle Ride Fee ($35)____

Event Day Registration: 5K Run/Walk Fee ($35)_____ Additional meal tickets ______ ($10 each) Additional Donation _________ Please Make Checks Payable to: Allies Angels

Mail Pre-Registration and Payment to: 50 Youngs Road Port Crane, NY 13833 I cannot attend Allie's Angels Ride, but I would like to donate and be a Friend of Allies Angels _________

Waiver and Release of Liability for 5K and Bicycle Ride Participants: I, ________________________________, am a willing participant in a fundraising and awareness event in support of children of the Southern Tier in memory of Allison Elizabeth. As part of this event, I agree to assume all risks and to release and hold harmless Allies Angel Ride, its officers, workers, sponsors, officials, volunteers, including event leaders. I intend by this Waiver and Release to release, in advance, and to waive my rights and discharge all of the persons and entities mentioned above, from any and all claims for damages, for death, personal injury, or property damage which I may have, or which may hereafter occur to me as a result of my participation in this event. I understand and agree that this Waiver and Release is binding on my heirs and legal representatives. I understand that I am solely responsible for my health and safety, and I acknowledge that I am physically capable of participating in and completing this event. I hereby agree to allow Allies Angels the use of my name and likeness (event photos, videos) for any purpose related to advertising or promotion of the event and/or Allies Angels without obligation or liability to me. I have carefully read this Waiver and Release and fully understand its contents. If I am under the age of 18 years of age at the time of registration, my parents or legal guardian has completely reviewed this Waiver and Release, understands and consents to its terms, and authorizes my participation by his/her signature below. I am aware that this is a RELEASE OF LIABILITY and a contract between me and the persons and entities mentioned above, and I sign of my own free will. Signature _________________________________________________Date:______________ Printed Name ______________________________________ Parent/Guardian Signature _________________________________Date_______________ Printed Name_______________________________________ Please return this completed form along with the registration form and a check payable to: Allies Angels, 50 Youngs Road, Port Crane, NY 13833