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LOCATIONAnsonia First Church of God // 750 South Main StreetAnsonia, OH 45303CAUSEProceeds from this event will be donated to a new out-reach ministry at Ansonia Church of God called “SecondSaturdays.” This ministry will complete various workprojects in order to build relationships and beautifythe community. A second benefactor will be a ministryorganization in Paraguay.COURSE5k (3.1 miles) is open to all runners and walkers – young and old. Strollers and dogs are welcome. A waterstation will be on course plus finish-linerefreshments.CONTACT INFORMATIONDavid Hackney 937.344.8395 [email protected] Reeder 937.417.8657 or [email protected]
RESULTS AND AWARDSRace will be timed from start gun to chip finish.Awards will be presented to the top three male/femaleparticipants in each age category.WHAT MAKES THIS SUCH A GREAT
EVENT►Family atmosphere and competitive runners►Door Prizes (must be present to receive door prize)►FREE Childcare (age 2+ // Bounce House &
Playground)►Post-Race Refreshments ►T-shirtRUNNING DIVISION►12 and under ►Teens ►20s ►30s ►40s ►50s ►60s
►70+COST$15 advance registration w/ shirt (postmarked by May
11)$20 late or day of registration (shirt not guaranteed)
SEND CHECK AND COMPLETED REGISTRATION FORM TO: Mad Dash for Missions 5K, 4194 Brown Road, Ansonia,OH 45303
Mad Dash for Missions 5K DAVE KNAPP FORD L-M INC
Saturday, May 21 @ 9 a.m. (Registration opens @ 7:30)
Clip, Complete and Return with Payment Name ______________________________________________________________ M F Birthdate ____/____/____ Age______ Address ___________________________ City _________________________ Zip ____________ Run Walk Telephone (_____)____________________ Email ______________________________________________________________________ T-Shirt Size (Circle One) Adult: S M L XL XXL(add $1) XXXL(add $2) Youth: S M Advance Registration by May 11 ______$15.00Late/Day of Registration ______$20.00General Donation (non-participant) ______(enter amount)Will you be using our childcare? Y / N If yes, how many children?_____ Ages of children__________Waiver of LiabilityI, intending to be legally bound, for myself, my heirs, next of kin, executors and administrators, voluntarily assume all risks of accident or injury and release and forever discharge, indemnify and hold harmless The First Church of God of Ansonia, and all employees, officers, sponsors and agents (collectively the “released parties”, from any and all liability for personal injury or property damage of any kind sustained during the Mad Dash for Missions Walk/Run whether such personal injury or property damage is caused by the gross negligence or carelessness of the released parties. I have full knowledge of the risks involved and attest that I am physically fit and sufficiently trained to participate in the athetic event. I grant permission to all foregoing to use any photographs, recordings or any other record of this event for any legal purpose. All dogs must be on a leash. Signature ____________________________________________ (Signature of participant, parent/guardian if under 18 years old)
Clip, Complete and Return with Payment Name ______________________________________________________________ M F Birthdate ____/____/____ Age______ Address ___________________________ City _________________________ Zip ____________ Run Walk Telephone (_____)____________________ Email ______________________________________________________________________ T-Shirt Size (Circle One) Adult: S M L XL XXL(add $1) XXXL(add $2) Youth: S M Advance Registration by May 11 ______$15.00Late/Day of Registration ______$20.00General Donation (non-participant) ______(enter amount)Will you be using our childcare? Y / N If yes, how many children?_____ Ages of children__________Waiver of LiabilityI, intending to be legally bound, for myself, my heirs, next of kin, executors and administrators, voluntarily assume all risks of accident or injury and release and forever discharge, indemnify and hold harmless The First Church of God of Ansonia, and all employees, officers, sponsors and agents (collectively the “released parties”, from any and all liability for personal injury or property damage of any kind sustained during the Mad Dash for Missions Walk/Run whether such personal injury or property damage is caused by the gross negligence or carelessness of the released parties. I have full knowledge of the risks involved and attest that I am physically fit and sufficiently trained to participate in the athetic event. I grant permission to all foregoing to use any photographs, recordings or any other record of this event for any legal purpose. All dogs must be on a leash. Signature ____________________________________________ (Signature of participant, parent/guardian if under 18 years old)
