5K Run & Mile Walk

4TH ANNUAL

When: Saturday, April 20th (Rain or Shine)

Race: 8 a.m. Chip timing and race results

Starting/Ending Location:

Pugh’s Diamond Jewelers1202 Brandywine Blvd. Zanesville

Entry Fee: $20 Runners• Event t-shirts to the first

50 pre-registered runners• Age group awards

$15 Walkers • Event t-shirts to the first

50 pre-registered walkers

Register: 7 a.m. Day of Event

Pre-Register at Pugh’s Diamond Jewelers

Mail To: Pugh’s Diamond Dash 1202 Brandywine Blvd. Zanesville, OH 43701

Online: www.pughsdiamonds.com www.teamgodspeed.org

Please make checks payable to Team GodSpeed. The registration fee is tax-deductible.

All proceeds from this event support Team GodSpeed’s

childhood obesity programs. Team GodSpeed is a non-profit athlete’s ministry that

promotes health, challenges minds and changes hearts.

Last Name: First Name: Age:

Address: City:

State: Zip:

E-mail: Home Phone:

Emergency Contact Name & Phone Number

Check the following:

p Female p Male p 5K Run p Mile Walk Circle Shirt Size Youth: S M L Adult: S M L XL

Registration

WaiverThe undersigned (“ATHLETE”) on behalf of himself/herself and on behalf of Athlete’s personal representatives, assigns, heirs, executors, hereby fully and forever release, waives, discharges and covenants not to sue Pugh’s Diamond Jewelers, Team Godspeed®, and all municipal agencies whose property and/or personnel are used, and all other sponsoring or co-sponsoring companies or individuals related to the Pugh’s Diamond Dash (collectively “RELEASES”) from all liability to the Athlete and his/her personal representatives, assigns, heirs, and executors, for all loss(es) or damage(s) and any and all claims or demands therefore, on account of inquiry to the Athlete or property or resulting in the death of an Athlete, whether caused by the active or passive negligence of all or any of the Releases or otherwise, in connection with the Athlete’s participation in the Pugh’s Diamond Dash. The Athlete represents and warrants that he/she is in good physical condition and is able to safely participate in the Pugh’s Diamond Dash. The Athlete is fully aware of the risks and hazards inherent in participating in the Pugh’s Diamond Dash, and hereby elects to voluntarily compete in the Pugh’s Diamond Dash, knowing the risks associated with the Pugh’s Diamond Dash. The Athlete hereby assumes all risk of loss(es), damage(s), or injury(s) that may be sustained by him/her while participating in the Pugh’s Diamond Dash. The Athlete agrees to the use of his/her name and photographs in broadcasts, newspapers, brochures and other media WITHOUT ATHLETE permission or compensation. The Athlete acknowledges that the entry fee is non-refundable and non-transferable. The Athlete hereby consents to receive medical treatment which may be deemed advisable in the event of injury, accident and/or illness during the event.

Signature: Date:

Guardian Signature:

(If Under 18 Years of Age)

For more information please contact Pugh’s Diamond Jewelers at 800.589.8464 or www.pughsdiamonds.com

Last Name: First Name: Age:

Address: City:

State: Zip:

E-mail: Home Phone:

Emergency Contact Name & Phone Number

Check the following:

p Female p Male p 5K Run p Mile Walk Circle Shirt Size Youth: S M L Adult: S M L XL

WaiverThe undersigned (“ATHLETE”) on behalf of himself/herself and on behalf of Athlete’s personal representatives, assigns, heirs, executors, hereby fully and forever release, waives, discharges and covenants not to sue Pugh’s Diamond Jewelers, Team Godspeed®, and all municipal agencies whose property and/or personnel are used, and all other sponsoring or co-sponsoring companies or individuals related to the Pugh’s Diamond Dash (collectively “RELEASES”) from all liability to the Athlete and his/her personal representatives, assigns, heirs, and executors, for all loss(es) or damage(s) and any and all claims or demands therefore, on account of inquiry to the Athlete or property or resulting in the death of an Athlete, whether caused by the active or passive negligence of all or any of the Releases or otherwise, in connection with the Athlete’s participation in the Pugh’s Diamond Dash. The Athlete represents and warrants that he/she is in good physical condition and is able to safely participate in the Pugh’s Diamond Dash. The Athlete is fully aware of the risks and hazards inherent in participating in the Pugh’s Diamond Dash, and hereby elects to voluntarily compete in the Pugh’s Diamond Dash, knowing the risks associated with the Pugh’s Diamond Dash. The Athlete hereby assumes all risk of loss(es), damage(s), or injury(s) that may be sustained by him/her while participating in the Pugh’s Diamond Dash. The Athlete agrees to the use of his/her name and photographs in broadcasts, newspapers, brochures and other media WITHOUT ATHLETE permission or compensation. The Athlete acknowledges that the entry fee is non-refundable and non-transferable. The Athlete hereby consents to receive medical treatment which may be deemed advisable in the event of injury, accident and/or illness during the event.

Signature: Date:

Guardian Signature:

(If Under 18 Years of Age)

For more information please contact Pugh’s Diamond Jewelers at 800.589.8464 or www.pughsdiamonds.com

Registration