Entry Form Habitat

The Inaugural Racin’ on the Rosebud 5K/1 Mile Race & Walk A fundraiser for Sicangu Tikaga Okiciyapi – Habitat for Humanity Saturday June 27, 2009 Day-of-race registration starts at 7:30 a.m. – 1 Mile starts at 9:00 a.m. – 5K and walk start at 9:30 a.m. ***All times are Central Time Zone.*** Prairie Hills Golf Course in Mission, South Dakota Located two miles south of the four-way stop (Junction of Highways 18 and 83 South) in Mission Habitat for Humanity International is a non-profit, ecumenical Christian housing ministry. HFHI seeks to eliminate poverty housing and homelessness from the world and to make decent shelter a matter of conscience and action. Sicangu Tikaga Okiciyapi is the Rosebud Indian Reservation’s local Habitat for Humanity affiliate. Since opening in 2000, we have partnered with 15 local families, helping them reach the goal of home ownership. Your registration fee and donation will allow us to continue our mission. Plus, 10 percent of all proceeds will be tithed to Habitat Kyrgyzstan. Your contribution and participation are greatly appreciated – both here and halfway around the world!

***There will be awards to the top performers in each race, as well as door prizes and post-race snacks and drinks.*** ***Your registration must be postmarked by June 13, 2009, in order to be guaranteed a t-shirt.*** Walkers:

All walkers will begin after the start of the 5K race to avoid congestion on the course.

Entry fee:

Age 17 and under: Age 18 to 54: Age 55 and over:

Mail entry forms to:

Racin’ on the Rosebud STO – Habitat for Humanity P.O. Box 327 Mission, SD 57555

$10 until June 13, $15 after June 13 $20 until June 13, $25 after June 13 $10 until June 13, $15 after June 13

For directions or more information, please either call (605) 856-2665 or e-mail [email protected].

We look forward to seeing you on June 27! -----

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Please print legibly – one entry form per participant Name:

_____________________________________

Race (circle one):

1 Mile

Address:

_____________________________________

Age on 06/27/09:

_______

City, State, ZIP:

_____________________________________

Sex:

M

Phone number:

_____________________________________

E-mail address:

T-Shirt Size (circle one):

S

M

L

XL

5K

Walker

F

___________________________________

No t-shirt

***Please check here  if you would like to pay the entry fee for a t-shirt, but do not plan on running or walking.*** I have enclosed $_______ for my race entry, plus an additional donation of $_______ for a total enclosed amount of $_______. Please make all checks payable to STO – Habitat for Humanity. Waiver and release: I know that running a race is a potentially hazardous activity which could cause injury or death. I should not enter and run unless I am medically able and properly trained, and by my signature, I certify that I am medically able to perform this event, and am in good health, and am properly trained. I agree to abide by any decision of a race official relative to any aspect of my participation in this event, including the right of any official to deny or suspend my participation for any reason whatsoever. I understand that bicycles, skateboards, baby joggers, roller skates or blades, animals, and radio headsets are not allowed in the race and I will abide by this guideline. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release STOHFH, the city of Mission, the Rosebud Sioux Tribe, and all sponsors, their 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.

Signature:

________________________________________

Date:

________________

If under 18, signature of parent or guardian: ________________________________________

Date:

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