2nd Annual Operation Restore Antwerp Redneck Run/Walk

Saturday, August 4, 2012 Antwerp, New York Come join us for our 2nd annual fundraising event. There will be three courses to choose from. A one mile leisure walk, a five kilometer run or our new ten kilometer run. All three events will start and finish at the Antwerp American Legion, Main Street, Antwerp. Registration will take place the day of the event however, you may preregister in person or by mailing your check, completed registration and waiver form to the address listed below. Mail-in registrations must be received by July 6, 2012. All participants that are registered by July 6, 2012 will receive a FREE t-shirt. Registration s will take place at the Antwerp American Legion for those who have not preregistered: Friday, August 3rd from 6:00 8:00 pm Saturday, August 4th from 7:30 8:45 am or by mail to: Karen Sands PO Box 661 Antwerp NY 13608 Please make checks payable to: Antwerp Fire Department with ORA on the memo line For further information or to download additional registration forms/waivers, type one of the following urls in your internet browser address bar http://www.facebook.com/OperationRestoreAntwerp or http://villageofantwerp.net/home Award Category There will also be awards by Age categories for runners (10K)- over all winners- Female/Male $100-1st prize, $50-2nd prize $25-3rd prize (5K) - over all winners- Female/Male $60-1st prize, $30-2nd prize, $15-3rd prize, (1M walk) Best Dressed Redneck costume - $50-1st prize, $25-2nd prize, $10-3rd prize
Walkers, You have to wear the costume to win the prizejust sayin Children Who Participate Will Receive a Free Ice Cream from the Village Market YAY!!

* Waiver must be signed to participate

Registration form for the 2nd Annual redneck walk/run

Last Name: ______________________ First Name:______________________ Race Day Age: ______ Gender________ Address: __________________________ City/ Zip: _______________________________ Phone: ______________________________ Email: ______________________________ Circle Event and Size ($20) 10k run ($15) 5k run ($10) 1 mile walk

T shirt Youth YS YM YL Adult S M L XL XXL Amount Paid: $ ______

Please make checks payable to: Antwerp Fire Department with ORA on the memo line

* Waiver must be signed to participate

WAIVER
I know that participating in this walk/run is potentially hazardous. I should not enter unless I am medically able and properly trained. I also assume any and all risks associated with this event including but not limited to falls, broken or sprained limbs, and contact with other participants, the effects of the weather, including high heat and/or humidity, and the condition of the roads and traffic, all such risks being known and appreciated by me. Knowing these facts, and in consideration of your accepting my entry, I hereby, for myself, my heirs, executors, administrators, or anyone else who might claim on my behalf, covenant not to sue, and waive, release and discharge the Village of Antwerp, and the Town of Antwerp, Jefferson County, the State of New York, and/or any agents authorized by them for any purpose. This release and waiver extends to all claims of every kind or nature, whatsoever, foreseen or unforeseen, known or unknown. Town of Antwerp/Village of Antwerp of Jefferson County is granted permission to use and /or publish my photograph or image (including audio, film, digital image or any other media) for entertainment or educational purposes.

Name of Participant ________________________________________________________________________ Signature of Participant/Guardian ________________________________________________________________________ Date