5K Run / 1 Mile Walk

To benefit Humane Society of Central Illinois

June 2, 2013
1 p.m. 3 p.m.
Feel Free to bring your dogs! All we ask is that you clean up after them.
Parking at Heyworth Centennial Park (Half a mile West of US 51 on Route 136)
Entry Fee: $25 (includes shirt)

** On-site registration available race day (no shirt)

Payable/Mail Checks to:

Heyworth High School East

308 W Cleveland
Heyworth, IL 61745

For more information call (309)-242-9096 or send an e-mail to 14davisj@husd4.k12.il.us

5K Run / 1 Mile Walk Entry Form

Name: ___________________________________________________________ Phone:________________________________________________
Address:_________________________________________________________________________________________________________________
City: ____________________________________ State:___________ Zip: _________________________
Email Address:__________________________________________________________________________
Payment Options: Race Fee $_________ with shirt

T-shirt size (Adult S-XL) ______________________

Check Payable to Heyworth High School East

Check # ___________________________ Amount $__________________
Donation
$__________
In consideration of the foregoing, I for myself, my executors, administrators and assignees, do hereby release and discharge Heyworth High School and other
sponsors and supporters of this race from all claims and damages, demands, actions, whatsoever in any manner arising or growing out of my participation in the
5K Run/1 Mile Walk. I understand I am responsible for my animal and any damages caused. I attest and verify that I have full knowledge of risk involved in this
event and that I am physically fit and trained to participate in this event.

Signature: ________________________________________________________________ Date: ____________

Parent/Guardian Signature: _______________________________________________ Date:_____________
If under 18 years of age