BRIARWOOD ELEMENTARY BULLDOG JOG ENTRY FORM DATE: October 1, 2016 TIME: 8 a.m. -­‐ 1 mile begins, followed by 5k Registration and check-­‐in begins at 7:15am. All participants should arrive at Hillcrest by 7:45am to line up. LOCATION: The event will start & finish at Hillcrest Covenant Church (at 87th Street & Nall). Participants will run/walk through beautiful surrounding neighborhoods and pass Briarwood Elementary. WHO: Students, parents, family, friends, neighbors, athletes! Anyone is welcome! (Sorry, no pets, bikes or scooters) Please note: To participate, each runner or walker must be registered to be on the course, even for an adult accompanying a child on the 1 mile run. Interested in volunteering during the jog? Contact Stephanie Lashley at [email protected] for information. *ALL* JOG PARTICIPANTS (use the back of this page if more than 6 participants) Preferred contact method for one participant (i.e. Cell number or email address) ____________________________________ Name Briarwood Teacher's name (if applicable) Grade Level 1. 2. 3. 4. 5. 6. Consent and Release: On behalf of myself, my child/children/dependent(s), I consent to participation in the Bulldog Jog, and hereby accept the risk that injuries, damages, or even death may occur. In consideration of me, and/or my child/children/dependent(s) being allowed to participate in the Bulldog Jog, on behalf of myself, my children/dependents, I release and agree to hold harmless the Bulldog Jog, Briarwood Elementary, the Briarwood PTA, Shawnee Mission School District, the City of Prairie Village, Johnson County, Kansas, and their respective agents, employees, representatives, affiliates, trustees, directors, volunteers, and contractors from any and all claims, demands, and causes of action arising out of any injuries, damages, or death caused, or emergency medical treatment provided, in relation to participation in this program. I give my permission for me, my child/children/dependents to receive emergency medical treatment when Event Representatives or Emergency Personnel deem it necessary. I have been warned that any participant must be in good health. I give permission for the free use of my name and picture in any broadcast, telecast, or print media account of this event. In filling out this form, I acknowledge that I have read and fully understand and do accept these restrictions. Signature/Parent Signature (if under 18) ______________________________________________________________________ FEE PAYMENT/DONATION • $5/Participant (Children 4 & under free): # of participants over 4 years old _____ x $5.00 = $________ • I am not able to participate this year or would like to make an additional donation in the amount of: $ ________ TOTAL: $__________ Payment Form ___ Cash or ___ Check (Payable to Briarwood PTA) ____ Sign in at www.myschoolanywhere.com and pay through “My Store” (please return signed form to school) Fill out entry form & send with payment to: rd
Briarwood Elementary School, Attn: Bulldog Jog, 6701 W. 83 St., O. P., KS 66204 100% of net proceeds benefit the Briarwood Elementary School community. Event Contact: Molly Lund, at [email protected]