Tree of Life 5K • ENTRY FORM
Make checks payable to SHF and
mail to
Safety And Health Foundation
c/o Jay Jacob Wind
611 South Ivy Street
Arlington VA 22204
By entering this event, I agree, warrant
and covenant as follows: I know that running is a potentially hazardous activity.
I should not enter or run in this event unless I am medically able and properly
trained. I agree to abide by any decision of a race official relative to
my ability to safely complete the run. I assume all risks associated with
running in this race including, but not limited to, falls, contact with other
participants, the effects of weather, including high heat and/or humidity,
the conditions of the road and traffic on the course, all such risks being
known and appreciated by me. Having read this waiver and knowing these
facts, and in consideration of your acceptance of my application, I, for
myself and anyone entitled to act on my behalf, waive and release Mercy Center Foundation U.S.A. Inc.,
Safety And Health Foundation Inc., Tree of Life synagogue, HIAS, USATF, RRCA, National Park Service, District of Columbia, and all sponsors,
their directors, elected and appointed officials, employees, officers, agents, representatives,
and successors from all claims or liabilities of any kind arising out of
my participation in this event even though that liability may arise out of
negligence or carelessness on the part of the persons named in this waiver.
I acknowledge that the application fee is non-refundable. I
agree that you may use my name and likeness for publicity purposes.
Signature _______________________________________________
(parent or guardian if under 18)
Name _____________________________________________________ Gender __ (M F) Age on 12/02/2018 __ __
Address __________________________________________________________________________________________
City _______________________________________________________________ ST __ __ ZIP __ __ __ __ __
E-mail _____________________________________________________________ T-shirt size [__] XS S M L XL XXL
Date of Birth __ __ - __ __ - __ __ __ __ (mm-dd-yyyy) Predicted time for 5K (3.1 miles) __ __ : __ __
Day Phone __ __ __ - __ __ __ - __ __ __ __ Evening Phone __ __ __ - __ __ __ - __ __ __ __
We keep all personal data private.
Enclosed is my entry fee
Juniors (19 & under) and Seniors (60 & over):
[__] $18 on/after October 1
[__] $20 on/after November 15
[__] $25 on/after November 30
All other adults:
[__] $36 on/after October 1
[__] $40 on/after November 15
[__] $50 on/after November 30
My event: [__] 5K Run at 10:00 AM [__] 5K Walk at 10:05 AM
Enclosed is an additional tax-deductible donation: [__]$25 [__]$50 [__]$100 [__] $250 [__] $500 [__] $1000 [__] Other: _________
Payable DIRECTLY to [__] Tree of Life synagogue [__] HIAS (we mail all such donations directly to the beneficiary)
You may also donate directly to Tree of Life synagogue using their PayPal page
You may also donate directly to HIAS using their web page
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