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2017 Buckley’s - Kennedy’s RunRunner Sponsors FormPLEASE PRINT CLEARLY
2017 Buckley’s - Kennedy’s RunRegistrati on Form
PLEASE PRINT CLEARLY
Sponsor’s Name Amount
1. ___________________ $ ____________
2. ___________________ $ ____________
3. ___________________ $ ____________
4. ___________________ $ ____________
5. ___________________ $ ____________
6. ___________________ $ ____________
7. ___________________ $ ____________
8. ___________________ $ ____________
9. ___________________ $ ____________
10. __________________ $ ____________
11. __________________ $ ____________
12. __________________ $ ____________
All sponsor donati ons are fully tax deducti ble.Make checks or money orders payable to
HeartShare Human Services
We strongly encourage you to ask family, friends and co-workers to sponsor you. If needed, you
may copy this sheet for additi onal sponsors.
First Name Last Name
Address
City State Zip
Phone
Gender:
Male Date of Birth Age
Female
T-Shirt Size: Have you run this race before?
Small Yes
Medium No
Large Is this a new address?
X-Large Yes
2X-Large No
Runner #_________ Amount: $ ___________
Waiver of Liability (Must be signed):I understand that HeartShare Human Services of New York and all other organizati ons or persons connected with this event are not responsible for any injuries which I may suff er while taking part in this event or as a result thereof. I hereby waive any claim of damages to my person and/or personal property.
Runner: __________________________________
_________________________________________Parent/Guardian (if runner is under 18 years old)
37TH ANNUAL
Buckley’s - Kennedy’s5K Charity Run
SUNDAY, MAY 21, 201710:00 AM • RAIN OR SHINE
In Loving Memory OfKevin “The King” Roche
andPudgie Walsh
All Proceeds Benefi t
37TH ANNUAL Buckley’s - Kennedy’s 5K Charity Run
SUNDAY, MAY 21, 2017 • 10:00 AM • RAIN OR SHINE
RUNNER INFORMATIONRunners arrive at 9:30 am in front of the Army Reserve Center, located on Rockaway Point Blvd/State Road between Barret Road and Hero Road in Breezy Point, NY. For GPS, use the address of St. Genevieve’s Church: 6 Beach 178th Street, Breezy Point, NY 11697 located across the street from the Reserve Center.
Runners clothing must be placed in plastic bags prior to race time. Immediately following the race, runners may pick up their clothes near the runners entrance to the Family Fun Day Picnic. Strollers are allowed behind the field of runners.
PARKING & SHUTTLE BUS INFORMATIONRunners and picnic guests may park in the Army Reserve Center parking lot. Shuttle buses will run between the parking lot and the Breezy Point baseball field from 8:30 am until 4:00 pm. You will not be able to park in Breezy Point.
TROPHY INFORMATIONTrophies are presented to the overall fastest male and female participants and to the top three males and females in each of the following age groups:
• 12 and under • 40 - 49• 13 - 19 • 50 - 59• 20 - 29 • 60 - 69• 30 - 39 • 70+
FAMILY FUN DAY PICNICAT BREEZY POINT BALL FIELD
11:00 AM - 3:00 PM
THE PICNIC IS OPEN TO THE GENERAL PUBLIC AND FEATURES:
• Live Music provided by Head Over Heels• Entertainment by DJ Suds• Games and Rides• Food and Beverages
You must be 21 or older to be served beer.The picnic is FREE for all registered runners and
children 12 and younger.
FOR MORE INFORMATION VISITwww.heartshare.org/eventswww.buckleyscaterers.com
Run Hotline Day of Race718.422.3347/3283 347.853.3722
RUN REGISTRATION FEES$25.00 Registration for adults 19 and older$30.00 Registration on day of the run $15.00 Registration for youth 18 and under
PICNIC NON-RUNNER FEES$20.00 Food and Beverages$25.00 Food, Beverages and T-ShirtChildren 12 and under are FREE
Methods of payment include VISA, MasterCard, American Express or Discover Card, or by check or money order payable to:
HeartShare Human Services of New York
The registration fee is waived for any adult runner collecting $50.00 or more or for any youth runner collecting $25.00 or more in sponsorships!
18 AND UNDER RUNNER WITH THEMOST SPONSORSHIP DOLLARS WINS
Samsung Galaxy Tab S2 (32GB)
Method of Payment: Visa Discover
MasterCard Check/Money Order
American Express Cash - On-site Registration ONLY!
Name as it appears on card
WAYS TO REGISTERRegister Online
Visit www.heartshare.org/events(Online registration closes May 19 at Noon)
Register By MailMail your completed application
(on reverse side) and payment by May 12 to:
37th Annual Buckley’s - Kennedy’s RunHeartShare Human Services of NY12 MetroTech Center, 29th Floor
Brooklyn, New York 11201
For runners registering by mail, numbers and T-shirts may be picked up during on-site registration at Buckley’s Restaurant
from May 18 to May 20, at times listed below.
Register In Person
Thursday, May 18 Buckley’s Restaurant - 3:00 pm - 8:00 pmKennedy’s Restaurant - 4:00 pm - 7:00 pm
Friday, May 19Buckley’s Restaurant - 3:00 pm - 8:00 pmKennedy’s Restaurant - 4:00 pm - 7:00 pm
Saturday, May 20Buckley’s Restaurant - 10:00 am to 8:00 pm
2 pm REGISTRATION PARTY at Buckley’sMusic - Giveaways – Food - Beer Specials
Kennedy’s Restaurant - 1:00 pm to 5:00 pm
Sunday, May 21Near Start Line - 7:00 am to 9:00 am
Buckley’s Restaurant 2926 Avenue S, Brooklyn, NY 11229
Kennedy’s Restaurant406 Bayside, Rockaway Point, NY 11697
Signature
Credit Card # Exp. date
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