2013 Leadership Road Race Registration Form

The 2013 Leadership Road Race will take place on April 13. There will be a Certified 5K course which will begin at 8:30 a.m. Then a 1 Mile Family/Pet Jog will begin at 9:15 a.m. A professional timer will be hired for race participants serious about collecting competitive race times.

DATE: April 13, 2013
LOCATION: Southwestern College, Winfield, KS
DISTANCES: Family Pet/Jog 1 mile or Certified 5K course

SCHEDULE:
5K: 8:30 a.m.
1 Mile: 9:15 a.m.

RACE PACKETS:
Packets will be available the day of the race. If needed before please contact us.

PRIZES:
Get creative with your running attire! Prizes will be awarded for both the top individual and group costumes.

Entry Fees

5K ENTRY FEES:
Postmarked on or before March 25: $20.00
Postmarked later or Race Day: $25.00

1 MILE ENTRY FEES:
Postmarked on or before March 25: $12.00
Postmarked later or Race Day: $15.00

GROUP DISCOUNT:
Teams of 5 people or more who register together will be discounted $3/person. Must register on or before March 25 to receive discounted rate.

Biographical Information

Last Name
First Name
Street Address
City
State
Zip Code
E-mail Address
Phone Number (Please include area code)

Student Credit

If desired, please specify a student name to receive
credit for this registration.

Payment

Please make checks payable to: Southwestern College Leadership

Send to:

Southwestern College
Attn. Leadership Road Race
100 College St.
Winfield, KS 67156

Signature

In consideration of my entry being accepted I, intending to be legally bound, do hereby waive, release, and forever discharge any and all rights and claims for damage which hereafter occur to me against Leadership Southwestern, Southwestern College, and all sponsors, volunteers for any injuries suffered by me against this event. I further state that I am in proper physical condition to compete in this race.

By typing my name in the Signature textbox below and submitting this online form I certify under penalty of perjury that all information provided is correct and complete and I agree to the terms and conditions of the waiver stated above.

Signature:

Signature of Parent/Guardian (if under 18):

Date:

Southwestern College is committed to a policy of nondiscrimination on the basis of race, color, gender, age, religion, national origin, handicap, or other nonmerit reasons, in admissions, educational programs or activities, and employment, all as required by applicable laws and regulations. Responsibility for coordination of compliance efforts and receipt of inquiries, including those concerning Title IX of the Education Amendments of 1972 and Section 504 of the Rehabilitation Act of 1973, has been delegated to the vice president for business affairs, Christy Administration Building, Southwestern College, 100 College Street, Winfield, KS 67156-2499, (620) 229-6000. Southwestern College complies with the Crime Awareness and Campus Security Act of 1990. The yearly report is available from the dean of students upon request. Race and ethnic origin information is voluntary and will not be used in a discriminatory manner.

Gender	Male Female
Birth Date
Age on Race Day
Are you registering as a group with a company, organization or team? If so, please indicate company/organization name:
Shirt Size (Guaranteed if registered by April 1)	S M L XL XXL
Event(s) of Participation	5K 1 Mile
I will be bringing a pet to the 1 Mile Family/Pet Jog	Yes