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PEGGY ZETTERSTROM MEMORIAL MUSIC SCHOLARSHIP

5K RUN/WALK

SATURDAY, MAY 14, 2011

BELVIDERE HIGH SCHOOL, OXFORD STREET, BELVIDERE, NJ

Registration: 8:30 am-10:00 am at the football field

Proceeds benefit: Peggy Zetterstrom Memorial Music Scholarship

(Scholarships given to seniors at Belvidere High School who have been involved in the music program)

Entry fees: $20 (Early bird rate $15 before March 15)

Awards presented to:

1st, 2nd and 3rd place winners in the 5K run

1st, 2nd and 3rd place overall Male/Female finisher in each age group

Age groups as follows: 10 & under, 11-14, 15-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70& up

Course: The Belvidere High School Cross-Country Course- Very fast, fairly flatto

Amenities: Shirts to pre-registrants and to post registrants while supplies last; Light refreshments
after the run/walk.

Directions: Route 80 East/West to exit 12-Route 519 south-continue to Rt. 46-cross over Route 46 and
continue to Blinking light-Turn right at light-go 1 mile-Belvidere High School is on the right.

From Phillipsburg: Route 519 North-through Lopatcong, Harmony and White. Turn Left at blinking
light and follow as above.

From Hackettstown: Route 46 west-Turn left onto Route 519 South (just past Hot Dog Johnny’s) –go 1
mile to blinking light and turn right; follow as above.

From Washington: Route 31 North to Route 46 West-follow as above


PEGGY ZETTERSTROM MEMORIAL MUSIC SCHOLARSHIP

5K RUN/WALK REGISTRATION

5K Run/Walk-Early Bird rate $15 before March 15-$20 after March 15.

Registration at 8:30 am at the football field-registration closes at 10 am

Start Time: 5K Run-10:00 am 5K Walk-10:15 am

One registration form and one waiver per person must be completed in order to participate

For additional forms go to: www.belvideresd.org and click on 5K Run/Walk

PLEASE PRINT

Last Name:__________________________________ First Name__________________________

Age (day or race)______________ Date of Birth______________ M/F____________

Address:_______________________________City__________________State____________Zip____

Email__________________________________________________

Shirts size (circle one) Adult: S M L XL XXL Youth: S M L

Entry Fee enclosed_________________

I am unable to participate but would like to make a donation of __________________

Please make checks payable to: Belvidere High School

Mail registration form, waiver form and payment to:

Belvidere High School, 809 Oxford Street, Belvidere, NJ 07823

Attn: Charlie Zetterstrom

For information call Charlie Zetterstrom @ 908-475-4025 x 124 Voicemail 751

Email: czetterstrom@belvideresd.org
PEGGY ZETTERSTROM MEMORIAL MUSIC SCHOLARSHIP 5K RUN/WALK

RELEASE, WAIVER AND PARTICIPATION AGREEMENT

Every participant and their parent or guardian, if the participant is below the legal age of 18,
shall read and execute this release, waiver, and participation agreement prior to participating in the
Run/Walk. (“Event”) By executing this registration form, I acknowledge that I have read and
understand the document and are bound by the terms contained in it. I recognize that my
participation could result in physical injury, death or property damage. I understand that such risks
cannot be eliminated without jeopardizing the essential qualities of the activity. These risks may also
occur as a consequence of my own actions, inactions or negligence, as well as actions, inactions, or
negligence of others, weather conditions, condition of equipment, condition of the facilities and
grounds and any first aid emergency treatment which may be administered. There may also be other
risks that are not foreseeable at this time.

With this knowledge, I release and forever discharge the School District (Belvidere), their
officers, directors, employees and all event sponsors, charities and all workers, employees, directors,
officers and individuals volunteering or participating in the event from any and all demands, causes of
actions, lawsuits, agreements, obligations, covenants, defenses, costs, liabilities and judgments,
whatsoever, known or unknown, suspected or unsuspected, whether they be in contract or in tort, in
law or in equity, which I may have against the School District arising my participation in the event. I
hereby waive all claims and demands against the School District for any loss, damage, injury (including
death) or claim of any kind, arising from, related to, or caused by my participation and agree to
indemnify, defend and hold harmless the School District from all loss, liability, damages, costs and
expenses (including actual attorneys fees) arising from or related to same.

The individual executing this release on behalf of a minor child, represents and warrants that
they are the parent and/or guardian of such minor child and that they will indemnify and hold the
School District harmless from and against any and all expenses, costs and damages, including
reasonable attorneys fees arising out of any claim by their child or other family member covered by
this application.

This release shall be effective for the event and has been freely executed by me.

Name of Participant (please print)____________________________________________

Signature (if under 18, signature of parent/guardian)__________________________________

Name (please print)_____________________________________________________________