Pulaski Area Swim Club
Polka Trot 5K Run / Walk
Date: Saturday, July 23, 2011
Time: 8:30 a.m. 5K run / walk
9:30 kid’s run (ages 4 – 9)
Checks payable to: Mail Registration Forms to:
PASC PASC
Polka Trot 5K
$20 (postmarked by 7/9) P.O. Box 486
$30 (postmarked after 7/9) Pulaski
WI 54162
½ mile kid’s run (free
for kids registered for 5K)
Place: Pulaski Middle School
911 S. St. Augustine
Pulaski, WI 54162
(north on Hwy. 32 to stoplight, left on Crest Drive to St.
Augustine)
Registration: 5-7 p.m. Friday night packet
pick-up at Pulaski Middle School
7– 8 a.m. (packet pick up and late registration)
Proceds to Benefit the Pulaski
Area Swim Club
Awards: age groups (10 & under);
(11-14); (15-19); (20-29); (30-39); (40-49);
(50-59); (60-69); (70 & over)
t-shirts for all
participants and drawings for door prizes
medals for all kid’s
run participants
Enjoy: Pulaski Polka Days events including: craft fair, polka days grounds,
fireman
water fights
Visit: www.pulaskipolkadays.com or
swimpasc.org . email swimpasc@hotmail.com
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First_______________________________________________
MI____________
Address__________________________________________________________________________________
City________________________________________
State _____ Zip
__________ Phone (____)___________________________ email ________________________________
5 K run ______ male_____ age
on race day _______
walk______ female_____ date of
birth ___/___/____
Adult t-shirt (circle size) small med. large x-large
xx-large Or Dry Weave Shirt
_______ Add extra $15 to fees
Kid’s Run _______ age on race day _______
In consideration of acceptance
of this entry in the Polka Trot 5K, I hereby freely agree, for myself, my heirs, executors and administrators, to
waive, release and discharge all rights and claims which I may have against the
sponsors of the event, organizer and promoter, the land owners, any and all
contributors and any and all workers, whether paid or voluntary, for any and
all damages which may be sustained by me or my family, directly or indirectly
in connection with my participation in, or travel to or from the event. I agree
to personally inspect all the race facilities and will refuse to participate if
I am not satisfied with the safety thereof. WI STAT 895.525(3)(4) “a
participant in recreational activities…accepts the risk inherent in the
recreational activity of which the ordinary prudent person is or should be
aware.”
If participant is under
age 18, parent or guardian must sign
Signature of participant____________________________________________________ Date __________________________
Signature of parent or legal guardian if minor________________________________________________________________________Date__________________________