DAN PATCH 5K PACE and 1-mile CLUB RUN Saturday June 22, 2013

Certified 5K RACE and 1-Mile Run!
5K - 9am - starts at Lifetime Fitness Savage NE side at 140th St.
1 mile - 10am - starts/ends in Community Park
CHIP TIMING Immediate Results!
Sponsored by DAN PATCH DAYS * LIFETIME FITNESS * SUBWAY *
TWIN CITIES ORTHOPEDICS * SAM's CLUB * Foundation 191 and
Laker Educational Foundation
" PROMOTING EDUCATION and HEALTHY LIFESTYLES "

SATURDAY JUNE 22, 2013

      9:00am 5K RACE  * 10:00am 1-MILE RUN
Check-in/On-site Registration  8:00am-9:00am.
Pre-Register until 6/15/2013.
5K Registration $20/adult $15/student.   WALKIN registration $5 extra.
1-MILE Registration $10/person.   WALKIN registration $5 extra.
All ages and abilities welcome - AWARDS in 10 categories!

RUNNER Information (one per registration)

* LAST NAME, First

* Address

* City

* State

* Zip

Phone

* Email Address

* RUNNING FEE

5K ADULT $20.00

5K STUDENT $15.00

1-MILE $10.00

* GENDER

Male

Female

* AGE

T-Shirt Size

* SCHOOL DISTRICT

Burnsville-Savage 191

Prior Lake-Savage 719

Other ( or support one above)

Check any/all that apply:

Please send me info. on other Foundation events.

I'd like to help at an event. Please contact me.

I'd like to promote my business and be an event sponsor or donate in-kind.

* Method of Payment

Mailing a check payable to LEF with this form, to PO Box 840, Prior Lake MN 55372 (PRINT FORM).

Charge my PayPal / Credit card (follow guest log-in)

* WAIVER: I know that running or walking a road race is a potentially hazardous activity. I should not enter and should not run or walk unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the course. I assume all risks associated with running or walking in this event, including but not limited to falls, contact with other participants, the effects of the weather including low temperature and/or wind chill, traffic and conditions of the road. All such risks are known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of this entry, I hereby for myself, heirs, executors and administrators waive any and all claims I may have for damages against Dan Patch Days, Foundation 191, the Laker Educational Foundation (LEF), the City of Savage, the State of Minnesota and all sponsors and individuals associated with the event, their representatives and successors and assignees for any and all injuries suffered by me in connection with this event, including pre and post race activities. I hereby grant permission to Foundation 191 and the LEF and its authorized agents to use my name, photographs, video tapes, motion pictures in connection with this event, including any other record of my participation in this event for any purpose. There will be a $20 fee for returned checks. Sorry, no refunds.

Agree

* Indicates Response Required