Bloemker & Bloemker Coaching and Road Race Management
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Race Times
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Distances
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you just ran)
Country &
Distance
Run
Grading
June 28, 2008 at 9:00 p.m.
Johnson County Community College
Flat, fast 5k on the outer campus drive of the college
Running Sports
Field News
Registration Form
Name:______________________________________________________________
Address:____________________________________________________________
City:___________________________________State_______Zip Code__________
Birthdate:____/____/_____Age____ Gender: Male/Female
Email:____________________________________Phone#____________________
Adult Shirt Size: S M L XL
Wavier/Release
I know that participation in a road race is a potentially hazardous activity. I will not enter and participate unless I am medically able and properly trained. I
agree to abide by the decision of a race official relative to my ability to safely complete the race. I assume all risk associated with participation in this
event, including but not limited to, falls, contact with other participants, and effects of weather, traffic, and road conditions. Having read this waiver,
knowing these facts and in consideration of our accepting my entry, I, for myself and anyone entitled to act on my behalf, waive, release and couenant
not to sue Garry Gribble Running Sports, Michael Bloemker, Katherine Bloemker, B & B race, Road Runners Club of America, USA Track and Field, Race
Officials, Sponsors or Volunteers, their representatives, successors, or assignees from any and all claims or liabilities of any kind arising out of or in
connection with my participation in this event. Including without limitation, claim or liability resulting from those matters described in this paragraph. This
release and waiver extends to all claims of any kind or nature whether foreseen known or unknown. The undersigned further grants full permission to Garry
Gribble Running Sports, Michael Bloemker, Katherine Bloemker, B & B race to use any photographs, video tapes, motion picture, recording, or any other
record of this event for any purpose. I agree not towear headsets, roller blades, or skates during this 5k event. I agree not to bring baby strollers or dogs onto
the race course.
________________________________________________________________________Date___________
Signature
________________________________________________________________________Date___________
Signature of Guardian if under 18 years of age
Mike Bloemker
B&B Race
PO Box 861076
Shawnee, Kansas 66286
or
sign up at active.com
