TAMPA POLICE
5K-1 MILE RUN/WALK
17thAnnual AnnualTampa TampaPolice Police Memorial Memorial Run 25th Run 5K & 1 Mile Run/Walk 5K & 1 Mile Run/Walk
IN COOPERATION WITH THE CITY OF TAMPA AND THE GASPARILLA DISTANCE CLASSIC ASSOCIATION IN COOPERATION WITH THE CITY OF TAMPA AND GASPARILLA DISTANCE CLASSIC ASSOCIATION SATURDAY, OCTOBER 8, 2011 - LYKES GASLIGHT PARK - RAIN OR SHINE! SATURDAY,5K OCTOBER 12, 2019COURSE - LYKES GASLIGHT PARK - RAIN OR SHINE! USATF CERTIFIED * CHRONOTRACK B-TAG TIMING
5K USATF CERTIFIED COURSE * CHRONOTRACK B-TAG TIMING 5K START: 8:00A.M. * 1-MILE FUN RUN/WALK: 9:00A.M. 5K START: 8:00 A.M. * 1-MILE FUN RUN/WALK: 9:00 A.M. PRE-REGISTRATION FEES (Online & By Mail)
PRE-REGISTRATION FEES (Online & By Mail) 5K - $20 1-MILE - $15 5K - $30 1-Mile - $20 REGISTER ONLINE AT ACTIVE.COM UNTIL MIDNIGHT ON SATURDAY, OCT. 1, 2011 OR FOR A DOWNLOADABLE ENTRY FORM, PLEASE VISIT REGISTER ONLINE AT IMATHLETE.COM UNTIL MIDNIGHT ON SATURDAY, OCT. 5, 2019 OR FOR A DOWNLOADABLE ENTRY FORM, TAMPAPOLICEMEMORIAL.ORG OR TAMPABAYRUN.COM. DO NOT MAIL AFTER SATURDAY, OCT. 1, 2011. MAKE CHECKS PAYABLE TO TAMPA POLICE PLEASE VISITMEMORIAL TAMPAPOLICEMEMORIAL.ORG. DO NOT MAIL AFTER SATURDAY, OCT. 5, 2019. FUND AND MAIL TO: TPMF, P.O. BOX 172995, TAMPA, FL 33672 MAKE CHECKS PAYABLE TO TAMPA POLICE MEMORIAL FUND AND MAIL TO: TPMF, P.O. BOX 172995, TAMPA, FL 33672 REGISTRATION AT SELECT SPORTS AUTHORITY LOCATIONS
LATE ONLINESATURDAY, REGISTRATION (UNTIL MIDNIGHT WEDNESDAY, SEPT. 24 & SATURDAY, OCT.ON 1 NOON – 5:00PM OCT. 9, 2019) 5K: $35 5K: $20 1-MILE: 1-MILE: $20 $15 RACE WEEK LATE REGISTRATION AND PICK-UP TAMPA – 4900 KENNEDY BOULEVARD; CARROLLWOOD – 12601 CITRUS PARK PLAZA DRIVE; BRANDON – 11335 CAUSEWAY BOULEVARD. TAMPA POLICE DEPARTMENT HEADQUARTERS - 411 NORTH FRANKLIN STREET OCT. 10 & FRIDAY, 11, 2019ON 11:00 AM - 7:00OCT. PM 5, 2011) LATETHURSDAY, ONLINE REGISTRATION (UNTILOCT MIDNIGHT WEDNESDAY, 5K:5K: $35 $20 $25 1-MILE: 1-MILE: $15 RACE DAY LATE REGISTRATION - TAMPA POLICE HEADQUARTERS, 2nd FLOOR RACE OCT. WEEK SATURDAY, 12,LATE 2019 REGISTRATION 6:30 AM - 9:00 AM TAMPA POLICE DEPARTMENT - 411 NORTH FRANKLIN STREET 5K:HEADQUARTERS $35 1-MILE: $20 THURSDAY, OCT. 6 & FRIDAY, OCT. 7, 2011 11:00AM – 7:00PM AWARDS: 5K: $25 1-MILE: $15 5K: TOP OVERALL M/F - TOP MASTERS M/F (40+) - TOP AGE GROUPS M/F (9 and under, 5 year increments 9 - 70+) 5K: TOP 3 SWORN LAW ENFORCEMENT (M/F) - NEIGHBORHOOD WATCH MOST PARTICIPATION PLAQUE RACE DAY LATE REGISTRATION - LYKES GASLIGHT PARK AMENITIES: SATURDAY, OCT. 8, 2011 6:30AM – 9:00AM T-SHIRT TO ALL PARTICIPANTS (MUST REGISTER BY OCT. 5, 2019 TO GUARANTEE SIZE) - DOOR PRIZES TO BE GIVEN AWAY 5K: $30 1-MILE: $15 COLUMBIA RESTAURANT’S BLACK BEANS & YELLOW RICE AND COLUMBIA’S ORIGINAL “1905” SALAD TO ALL FINISHERS AWARDS: 5K: TOP OVERALL M/F - TOP MASTER’S M/F (40+) - TOP AGE GROUPS M/F (8 and under, 5 year increments 9-70+) 5K: TOP 3 SWORN LAW ENFORCEMENT - NEIGHBORHOOD WATCH MOST PARTICIPATION PLAQUE AMENTITIES: T-SHIRT TO ALL PARTICIPANTS (MUST REGISTER BY OCT. 1, 2011 TO GUARANTEE SIZE) - DOOR PRIZES TO BE GIVEN AWAY COLUMBIA RESTAURANT’S BLACK BEANS & YELLOW RICE AND COLUMBIA’S ORIGINAL “1905” SALAD TO ALL FINISHERS
VIKING FAMILY SECURITY
Tampa Police Memorial 5K & 1 Mile Run/Walk 5K: $20 1 MILE: $15 OFFICIAL USE: RACE NO. Tampa Police Memorial 5K & 1 Mile Run/Walk OFFICIAL USE: RACE NO. _________________________ LAST NAME: FIRST NAME: Tampa Police Memorial 5K & 1 Mile Run/Walk OFFICIAL USE: RACE NO. _________________________ LAST NAME: ___________________________________________________ FIRST NAME: ________________________________________________ Tampa Police Memorial 5K & 1 Mile Run/Walk OFFICIAL USE: RACE NO. _________________________ STREET ADDRESS:
LAST NAME: ___________________________________________________ FIRST NAME: ________________________________________________ CITY: CITY: STATE: STREET ADDRESS: ___________________________________________ __________________________ STATE: ____ ZIP: ZIP: ____________ LAST NAME: ___________________________________________________ FIRST NAME: ________________________________________________ STREET ADDRESS: ___________________________________________ CITY: __________________________ STATE: DATE ____ OF ZIP:BIRTH: ____________ / (W) RACE DAY,OCT OCT.128 _________ DATE TELEPHONE: (H) _________________ (W) _________________ AGE AGEON ON RACE DAY, OF ____ BIRTH: _____/_____/_____ STREET ADDRESS: ___________________________________________ CITY: __________________________ STATE: ZIP: ____________
TELEPHONE: (H)
TELEPHONE: (H) _________________ (W) _________________ AGE ON RACE DAY, OCT 12 F SEX: 5K ❏ 5K ❏ 11MILE MILE T-SHIRT SIZE: (Circle) M _____(H) F _____ T-SHIRT SIZE: (Circle one) YL DAY, S YOUTH MOCT L XL TELEPHONE: _________________ (W) _________________ AGE ON RACE 12
SEX: M SWORN LAW TPD:
_________ DATE OF BIRTH: _____/_____/_____ MBIRTH: _____/_____/_____ L XL XXL S _________ DATE OF
/ XXL
SEX: M _____ F _____ ❏ 5K ❏ 1 MILE T-SHIRT SIZE: (Circle one) YL S M L XL XXL SWORN LAW ENFORCEMENT: ❏1 YES AGENCY NAME: ________________________________________________________________ ENFORCEMENT: NO AGENCY NAME: SEX: M _____ F _____ YES❏ 5K ❏ MILE❏ NO T-SHIRT SIZE: (Circle one) YL S M L XL XXL
Y
N
SWORN LAW ENFORCEMENT:
TPD: ❏ YLAW ❏ N ENFORCEMENT: DISTRICT: DISTRICT: 1 ____ 1 SWORN
❏ YES ❏ NO AGENCY NAME: ________________________________________________________________ ____ 3 3 ____ HQ NEIGHBORHOOD WATCHWATCH GROUPGROUP NAME: NAME: _____________________________ 2 2 ____ HQ NEIGHBORHOOD ❏ YES ❏ NO AGENCY NAME: ________________________________________________________________
TPD: ❏ Y ❏ N DISTRICT: ____ 1 ____ 2 ____ 3 ____ HQ
NEIGHBORHOOD WATCH GROUP NAME: _____________________________
MAKE❏CHECKS PAYABLE ____ AND 1 MAIL TO: TAMPA POLICE MEMORIAL FUND, P.O. BOX 172995, FL 33672 Y ❏ NTO: DISTRICT: ____ 2 ____ 3 ____ HQP.O. NEIGHBORHOOD WATCH _____________________________ MAKE CHECKS PAYABLETPD: AND MAIL TAMPA POLICE MEMORIAL FUND, BOX 172995, TAMPA, FL GROUP 33672TAMPA, (NAME: POSTMARKED BY: 10/01/11)
PRE-REGISTRATION: 5K: $30 and 1 MILE: $20 (5K-$35 after midnight 10/5/19 and $35 on race day) MAKE CHECKS PAYABLE AND MAIL TO: TAMPA POLICE MEMORIAL FUND, P.O. BOX 172995, TAMPA, FL 33672 CHECKS PAYABLE AND MAIL TO: POLICE MEMORIAL FUND, P.O. BOX 172995, TAMPA, FL 33672 AMOUNT ENCLOSED: MAKE (Registration FeeTAMPA is NOT refundable) HERE IF DONATION ONLY (Not running in race) PRE-REGISTRATION: 5K: $30 and 1 MILE: $20 (5K-$35 after midnight 10/5/19 and $35 CHECK on race day) AMOUNT ENCLOSED:5K: ______________ (Registration Fee is NOT Refundable) PRE-REGISTRATION: $30 and 1 MILE: $20 (5K-$35 after midnight 10/5/19 $35 on race day) WAIVER OF RESPONSIBILITY - I know that road race is a potentially hazardous activity. I should not enter the run unless Iand am medically able and trained. I agree to abideI by anytodecisions of a race official related to WAIVER OFaRESPONSIBILITY - I know that a road race is a potentially hazardous activity. I should not enter the run unless I am properly medically able and properly trained. agree abide by run. any decisions of race associated official related to my abilityor to walking safely complete the run.including I assume but all risks orwith walking in this event, including but notof limited to, my ability to safely complete the I assume allarisks with running in thisisevent, not associated limited to,with falls,running contact other participants, the effects the weather, including high heat and/or AMOUNT ENCLOSED: ______________ (Registration Fee NOT Refundable) falls, contact with other participants, the effects of the weather, including high heat and/or humidity, traffic, and the condition of the road. All such risks being known and understood WAIVER OF RESPONSIBILITY I know that a road race is a potentially hazardous activity. I should not enter the run unless I am medically able and properly trained. I agree to abide AMOUNT ENCLOSED: ______________ (Registration Fee is NOT Refundable) humidity, traffic, and the conditions ofHaving the road. such risks being known and understood by me.ofHaving read this knowing these facts, in consideration of your accepting my entry, I, for myself, and anyone by me. readAll this waiver and knowing these facts, in consideration your accepting mywaiver entry, I,and for myself, and anyone entitled to act on my behalf, waive and release the by any decisions of a race official related ability complete the run.activity. I assume all risks with running walking able in this event, including butI agree not limited to, WAIVER OF RESPONSIBILITY - I know thattoa my road race to is asafely potentially hazardous I should not associated enter the run unless I amor medically and properly trained. to abide Tampa Police Department, the Tampa Police Memorial Fund, and all sponsors, their representatives, and successors from all claims of liability of any kind arising out of my particientitled to act on my behalf, waive and release the Police Department, the Police Memorial Fund andallallrisks sponsors, from allwalking claims of liability ofincluding anyknown kind arising out of falls, contact with of other participants, the effects the weather, high humidity, traffic, andsuccessors thewith condition of the road. All such risks being and by any decisions a Tampa race official related to myof ability toTampa safelyincluding complete theheat run.and/or I assume associated running or in this event, but notunderstood limited to,my participation in this event.
E-MAIL ADDRESS: SIGNATURE
pation in this event. by me. Having read thisparticipants, waiver and knowing these facts, in consideration of your accepting my entry, I, for myself, and anyone entitled to act onrisks my behalf, waive and and understood release the falls, contact with other the effects of the weather, including high heat and/or humidity, traffic, and the condition of the road. All such being known Tampa the Tampa Police Memorial Fund, and all sponsors, their representatives, and successors from all claims of liability arising out of release my particiby me. Police HavingDepartment, read___________________________________________ this waiver and knowing these facts, in consideration of your accepting my_______________________________ entry, I, for myself, and anyone entitled toNUMBER: act of onany my kind behalf, waive and the E-MAIL ADDRESS: EMERGENCY CONTACT: PHONE __________________________ pation in this event. EMERGENCY CONTACT: NUMBER: Tampa Police Department, the Tampa Police Memorial Fund, and all sponsors, their representatives, and successors from all claims of liability ofPHONE any kind arising out of my participation in this event. E-MAIL ADDRESS: ___________________________________________ EMERGENCY CONTACT: _______________________________ PHONE NUMBER: __________________________ E-MAIL ADDRESS: ___________________________________________ EMERGENCY CONTACT: _______________________________ PHONE NUMBER: __________________________ __________________________________________________________________________________ ______________________________________________________________________________ SIGNATURE DATE PARENT/GUARDIAN SIGNATURE (if under DATE DATE PARENT/GUARDIAN SIGNATURE (if under 18)18) __________________________________________________________________________________ SIGNATURE DATE __________________________________________________________________________________ SIGNATURE DATE
DATE
______________________________________________________________________________ PARENT/GUARDIAN SIGNATURE (if under 18) DATE ______________________________________________________________________________ PARENT/GUARDIAN SIGNATURE (if under 18) DATE
tampapolicememorial.org
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