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Run to Rebuild Haiti 5k Entry Form Name: _______________________ Age: ________ Gender: M F T-Shirt Size: S M L (t-shirts available on first come first serve basis) Entry Fee: $15.00 (Checks made out to Sarah Kjorlien)

WAIVER: KNOWING THAT RUNNING AND BICYCLE RACING ARE POTENTIALLY HAZARDOUS ACTIVITIES, I ENTER TO RUN THIS RACE CERTIFYING THAT I AM MEDICALLY IN GOOD HEALTH AND PROPERLY TRAINED. I ALSO KNOW THAT, ALTHOUGH SAFETY PROTECTION IS PROVIDED, THERE MAY BE TRAFFIC AND OTHER RISKS ASSOCIATED WITH PARTICIPATING IN THIS EVENT. I ASSUME ALL RISKS OF RUNNING AND BIKING IN THIS EVENT. I HEREBY, FOR MYSELF AND ANYONE ENTITLED TO ACT ON MY BEHALF, WAIVE AND RELEASE GRAND ITASCA FOUNDATION, GRAND ITASCA CLINIC & HOSPITAL, VACATION SPORTS, AND ANY OTHER PARTIES ASSOCIATED WITH KICKIN始 LEAVES DUATHLON, FROM ALL CLAIMS OR LIABILITIES OF ANY KIND ARRIVING OUT OF MY PARTICIPATION IN THIS EVENT. FURTHER, I GRANT FULL PERMISSION TO USE ANY PHOTOGRAPHS, VIDEOS, RECORDINGS, OR ANY RECORD OF THIS EVENT FOR ANY PURPOSE. I HAVE READ THE FOREGOING AND CERTIFY MY AGREEMENT BY MY SIGNATURE BELOW. Signature: ________________________________________________________________ Date: ___________

(By parent or guardian if participant is under 18 years of age)

Completed forms should be sent to: Kjorlien- Run to Rebuild 2002 NW 9th Ave Grand Rapids, MN 55744


Run to Rebuild Haiti 5k When: Saturday June 11th 9:15 Registration Open 10:00 Race Start Where: Forest History Center Trails behind Grand Itasca Clinic and Hospital 1601 Golf Course Road Grand Rapids, MN 55744

Participants can register on the morning of the race, or print out the registration form attached and send it in with payment. Earlier registration means better chance of getting a t-shirt. Although this is called Run to Rebuild, running is not required to participate in the 5k. You can run, walk, skip, jump, shuffle; whatever mode of self-propulsion you desire! Pets ARE allowed. We will be collecting donations for Lutheran World Relief, the organization we have been sending our funds through all year, and we encourage participants to find people to sponsor their 5k to help raise even more help for Haiti! 


Run to Rebuild 5k Entry Form