King of the Hill Fundraiser -- Race Entry Form

Register for the race and create your own online fundraising page!

IMPORTANT NOTE:
Payment of your race registration fee is not due at this time. Following submission of this form, you will be prompted to create your online fundraising page at active.com.

First Name (Required)

Last Name (Required)

Address (Required)

City (Required)

State (Required)

Zip Code (Required)

Phone Number (Required)

E-Mail Address

Company

Gender (Required)

Male
Female

Date of Birth (Required)

/ /

Your Age on Race Day (Required)

To show our appreciation, United Way of Western Connecticut may publish a list of fundraisers in print and online media following the King of the Hill Road Race. I approve of public acknowledgement of my gift.

Waiver: I know that entering a road race is a potentially hazardous activity. I will not enter and participate unless I am medically able and properly trained. I assume all risks from participating in this event and its related activities, including but not limited to, falls, contact with other participants, effects of the weather, traffic and the other conditions of the road; all such risks being known and appreciated by me. Having read this waiver and release and knowing these facts and in consideration of your accepting my entry fee and participation, I, for myself, my heirs, executors, administrators and anyone entitled to act on my behalf, waive and release the United Way of Western Connecticut, Berkshire Industrial Corporation, Berkshire North LLC, Berkshire West LLC, the owners and tenants of all property within the Berkshire Corporate Park (said Corporate Park is located within the City of Danbury and the Towns of Bethel and Brookfield), the city of Danbury, the Towns of Bethel and Brookfield, and the owners, operators and residents thereof, race officials, individual runners / walkers welcome volunteers, all event sponsors and all others including the respective affiliates, subsidiaries, principals, directors, agents, officers, employees and contractors of any of the foregoing) of and from all claims, damages, liabilities or cause of action of any kind arising out of my participation in this event or its related activities which I or my successors, assigns or heirs may ever have now or in the future against any of them. I grant permission to all the foregoing to use any photography, motion pictures, recordings or any other record of this event for any lawful purpose including the use of my name, my picture, and/or my voice. I know that dogs, bicycles, in‐line skates and baby joggers are not allowed on the course.

King of the Hill Fundraiser -- Race Entry Form

Register for the race and create your own online fundraising page!

IMPORTANT NOTE:Payment of your race registration fee is not due at this time. Following submission of this form, you will be prompted to create your online fundraising page at active.com.

RACE SPONSORS

IMPORTANT NOTE:
Payment of your race registration fee is not due at this time. Following submission of this form, you will be prompted to create your online fundraising page at active.com.