Burke Heels and Wheels 5K and Kids Fun Run 2014

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1 Race Day Schedule Sunday, October 19th 7:30 AM Registration Begins 8:30 AM Registration Closes 5K Racers 8:45 Warm-Ups and Announcements (at track) 9:00 5K Race Begins 10:30 Kids Fun Run Registration Closes 11:00 AM Kids Fun Run Begin 11:30 Announcements, Awards and Refreshments Registration Fees : $25: Adult Advance Registration $30: Adult Registration after 10/3 and on Race Day $10: Youth (age 15 and under) Advance Registration $15: Youth (age 15 and under) Registration after 10/3 and on Race Day Free: Children Under 4 Fee includes: Event T-Shirt Numbered Bib Who can participate? This year we are happy to welcome runners, walkers and families to participate in our 5K event. Please no strollers on the race course. Where will the race be? The race will begin and end on the Burke Campus. More information? Kathleen Edsall kedsall@burke.org We look forward to seeing you, your family and friends on October 19th.

2 INSTRUCTIONS FOR COMPLETING THE REGISTRATION FORM 1. We will have 8 classes: 1st, 2nd, 3rd Place Runner Male & Runner Female o 13-18, 19-30, 31-40, 41-50, 51-60, 61+ 1st, 2nd, 3rd Place Wheelchair Male & Wheelchair Female 1st, 2nd, 3rd Place Hand Cycle Wheelchair Male & Hand Cycle Wheelchair Female **All Wheel Chair Participants must be able to self propel** 2. Kids Fun Run participants will receive a participation ribbon. 3. We will have three races: Prizes will be awarded for each category. Ages 4 5: 100 yard dash Ages 6 8: 1/4 mile run Ages 9 12: 1/2 mile run 4. In addition to the registration form, you must complete, sign and submit the Release of Liability and Permission to Photograph/Video Section. 5. If you live in Westchester County you may apply for transportation through the Westchester County Office for the Disabled. Contact them directly at: Westchester County Office for the Disabled Attn.: Para Transit 148 Martine Avenue, Room 102 White Plains, NY Tel: (914) We reserve the right to cancel any event due to lack of participation.

3 ATHLETE REGISTRATION FORM Heels and Wheels 5K Race 10/19/14 Last Name: First Name: Address: City: State: Zip: Home Phone: Work Phone: Address: Date of Birth Age Male Female I am participating as a walker I am participating as a runner I am participating with my wheelchair I am participating with my hand cycle wheelchair T-Shirt size: S M L XL XXL Child: In addition to my registration I would like to donate $ to the Burke Rehabilitation Hospital. **You must return your registration by 10/3/2014** We reserve the right to cancel any event due to lack of participation. The Burke Rehabilitation Hospital Memo: Heels and Wheels 5k 785 Mamaroneck Avenue White Plains, New York 10605

4 EVERY ATHLETE MUST COMPLETE & RETURN THIS FORM ALONG WITH THEIR REGISTRATION & PAYMENT by 10/3/14. Note: You will not be able to participate unless this release is signed. RELEASE OF LIABILITY (required for athletes) In consideration of acceptance of this entry form, I/we the below signed, intending to be legally bound, hereby for myself/ourselves, our heirs, administrators and assigns, waive and release any and all claims for damages against The Burke Rehabilitation Hospital, Westchester Road Runner, any and all sponsors and their representatives, volunteers, and successors and assignees for any and all injuries and/or expenses incurred by me/us at the Burke Heels and Wheels 5K road race to be held on Saturday, September 28, I further attest to that I am physically qualified to participate in the race and do not suffer from any major illness that would make my participation a medical risk. Printed Name of Competitor: Signature of Competitor: Date: Legal Guardian: Date: (If under the age of 18) PHOTO / VIDEO RELEASE I hereby authorize the Burke Wheelchair Games to take and use photos and/or video of me during the meet for publicity purposes and/or for use in future programs. I understand that these photos and/or video may be included in printed publications and/or posted on Burke s website and social networking sites. Printed Name of Competitor: Signature of Competitor: Date: Legal Guardian: Date: (if under the age of 18) **You must return this form with your registration by 10/3/2014** We reserve the right to cancel any event due to lack of participation. The Burke Rehabilitation Hospital Memo: Burke Heels and Wheels 5K 785 Mamaroneck Avenue White Plains, New York 10605

5 If you would like to volunteer please contact Kathleen Edsall at

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