7/28/2019 Rock the Block.2013.Entry Form

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ROC THE DTOCK RUN * REI*aysK Racn / r Mtrr Euirr Rulr/ 4 Mrrr-4 MAT\r Rnray(Waricrns Wurcous Fon sK aND 1 Mnr Evrmrs!!)Saturday, Augugt 24, LotS at 6:oo P.M.Clay County Courthouse, Louisville, IliinoisProceeds will help Organization for Autism Research (O-e-R.) via

Bank of America Chicago llarathon zor3 Charity Team member ffelanie PearceIn conjunction with Louisvilles Block earty * Live Entertainment and Free Dinner (Louisville Rotary CIub setting &inls)*Chip Timing Services by ChanrpionChip for SK & r l{jle Event*PREREGISTMTI0Tf/REGISTRATI0If FEES FOR sK & r ttlileIf entry forms neceived on or before August lf: SK: $zo r it{ile $rz *Ifo rcfunds due to weatherSame Day Registration Available SKr $zS r }Iile $rS *Course closes 7oo P.lf.PREREGISTRA?I0I\I FEES FOR REtAy: 4-IfAI{ TEAIII FEE: $6o.oo on or before August rg

*Ifo Sarne Day RegiskaUon Available for Relay *Relay will begin at approxirnately 54S p.m.Final registration for 5K & r }Iile and Packet Pick-up begins outside the Cou{house at 4go Ptrf the day of the race and closes at 56o Pir{.dl those pre'registered by August rf are assured of receiving a .lfoisture lfanagement T-shirt.Extra shirts urill be orderd but rvil be available only while sqpplies last to those registered after August rgth

Awards ceremony immediately following RelayEVEIYT: c.e.rtconr (crncu orrt5( Rur For SK, t( Overall .l{ale/Female and I't and 2"d Age Category lrfale/Femaleu & under, u-r5, 16-18; tg-24; zS-54; Tg-44; 41-yl; 55 & olderr ltlrr Frn Rur For r trfflg I't overall l{ale/FemaleRE[ltY r* tty rgr ronowrr{c cATE@Rr[s: Au Frrce; Au tr{rue; I,tr,wto l[at.l/FEtraru (Co-zo);u & Urorn (ln rrmrns u yoA AIvD urorn); rS - rg ToA (ALL }frrrrns tg yoA AilD urorn);

trfurs trfusftns (flcr UEUBER ulut, & 4o roe on ornen); Ftmre trf^e,srrns (racr rrmrn rruam & 40 yolon ororn)Pulsr cIRcIJ rouR T-sf,ItrT slz[. IF HoT ]TARKED, you wtl.r ftrcEryE .a llmruy.YOUTH SIZE: SIfALT lr{EDIUff IABGE IDaLT SIZE: SI{AII [rpIuu l..encr X-I.ancr *XXI. f,ADD $2Nlnrn Ir Rnurv, TEAM NAMI & Trau l,LmAcrr

ANPRNSS CITY STATB Z,IP E,NIAIL:\DDRE,SS PHONE AGE oN DATE o}. RL1N GENDER

Maxr CuEcxs P,lvAsrE ro: RocK THE BLocK RUNMAIL ENTRY [oRM To: ATTN: Rocx r]rE BLocK RUN & Rrlilr, P.O. Box 190, Loursvrll-E, IL 62858

OR DRop orr lr: Loulsvr LLE Crry HALL, LouISvILt-E, ILOTHER CoN'rAcr INToRMATIoN: psitr'_sg!,1n_q.trrn,-cs_,tt OR CALr. MELANIE PEARcE @ (618) 508-2755

F.qcEeoox PAGE: RocK THE Br-ocK RUN & REr.Ay Loursl,rr.r n Br ()cx P,lnrY

Waiver: By signing below, I do hereby release and discharge from liabitity O.A.R., the City of Louisville,organizers, event sponsors, supervisors of the'BocE rxr BtocK RUN 4 BELaY- and their representatives,successors and assigns for any and all causes of action, claims, and iniuries suffered by me in this event,however incurred. I attest and verify that I have sufficiently trained for the completion of this event. As aparent or guardian of the applicant (if applicant under the age of 18), I hereby consent to the participation of theapplicant in the race under the above mentioned conditions.Signature Dat-e

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