5K / Run
Saturday, June 25
5K Run or 5K Walk
Medals will be awarded to 1ST - 3RD place runners in each age group.
PRE-REGISTRATION DEADLINE: JUNE 17, 2011 Registration is 6:30-7:15 AM Olympiad starts at 7:30 AM Cost is $15 If you pre-register before June 17 you’ll receive a free T-shirt, or you can register the day of the race. Registration tables will be set up in the east hospital parking lot and the Olympiad will start on Avenue A directly east of the Hospital. Waiver! I hereby waive and release all rights and claims for damages I may have against the organizers and sponsors of the OLYMPIAD (including Good Samaritan Hospital and Kearney Park and Recreation Department) to be held on Saturday, June 25, 2011, for any and all injuries suffered by me in these events. I hereby authorize the organizers and support personnel at the OLYMPIAD to obtain any appropriate medical aid I may require during these events. I agree to the use of my name and picture in publicity and media coverage.
_________________________________ Your Signature
__________________________________ Parent/Guardian Signature (if 18 or younger)
Hurry! Advance entries are due June 17. Only those pre-registered will receive a free T-shirt. Please pick up your race packet at the registration table. Mail! this form and your $15 entry fee payable to: Good Samaritan Hospital· OLYMPIAD P.O. Box 1990 · Kearney, NE 68848-1990
Walk slowly or run a fast race– There’s a division for everyone! If you are registered for the Olympiad through the Community Olympic Games, you’re already entered! For more information please call 308-865-2275. ONLY pre-registrants will get a free T-shirt. Name ____________________________________________ Address __________________________________________ Phone ____________________________________________
City / State / Zip ________________________________ male female event 5K Run 5K Walk
age division 13 & under 14 - 17 18 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 & older
t-shirt size Youth S Youth M Youth L Adult S Adult M Adult L Adult XL Adult XXL