Jackson County 4-H Pancake Fun Run

3rd Annual Jackson County
4-H Pancake Fun Run
sponsored by Jackson County 4-H County Council
Sunday, July 25th
| 8:00am
This race is a fundraiser, planned by the Jackson County 4-H County
Council. All proceeds will benefit Together We Build, the campaign to
construct a new Outreach Center for the Jackson County Extension /
Jackson County Fair.
Come for a run and stay for the pancakes!
Early Registration = $25 includes race, race day shirt, and 4-H Endowment pancake breakfast ticket
$20 includes race and 4-H Endowment pancake breakfast ticket (no shirt)
Day of Race Registration = $25 includes race and 4-H Endowment pancake breakfast ticket
Check-in for races and day of race registration begins at 7:15am at Volunteer Hall.
Kid’s Fun Run begins at 8:00am. Adult Fun Run begins at 8:30am. Both races will travel around the fairgrounds.
Join us for the Jackson County 4-H Endowment Pancake Breakfast after the race at Pearson Hall, 8:00am – Noon.
Registration form and payment due by July 15th to guarantee your pancake shirt at race time!
Questions? Contact Brittany Moore at [email protected]
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2021 Jackson County 4-H Pancake Run Registration Form
Complete the registration form and return with payment to Jackson County Extension, 201 West Platt St., Maquoketa IA 52060
Checks payable to Jackson County Extension Due July 15th!
Name: ______________________________________________________________________________
Address: ______________________________________________________________________________
Phone: _____________________________________ Email: ______________________________
Age on Race Day: _______________________________ Birthdate: ___________________________
Emergency Contact: _______________________________ Phone: _____________________________
T-Shirt size: Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult Extra Large No Shirt
Event: Fun Run (13 & older)_______ ($25 with shirt, $20 without shirt) Kid’s Run (12 & under) _______ ($25 with shirt, $20 without shirt)
Permission, Release, and Waiver of Liability: This event Agreement and Release and Waiver of Liability shall be governed by and construed under the laws of the State of Iowa, which shall be the forum for any lawsuits
arising from or incident to this Agreement. I understand that running and/or walking are strenuous and potentially dangerous activities. I am fully aware of and assume all risks associated with this event including but not
limited to: great physical stress, falls, contact with other runners, spectators or obstacles, adverse weather and road conditions, and the presence of vehicular traffic on the race course. I fully assume responsibility for my
and my child’s own safety (including proper training, stretching, and hydrating) while participating in this event and verify that I and/or my child am/is physically able to compete. I consent to the use of photographs, video
and/or interview information of me or of my child. I authorize medical treatment deemed advisable by any licensed health care provider to relieve any injuries or illness while a participant or observer. I understand that no
accident or medical insurance for participants is provided and that that I am financially responsible for charges to the attending physicians or health care unit. I understand that shirt size cannot be guaranteed. I
acknowledge that the entry fee is non-refundable and non-transferable. I certify that I have read this document and agree with its contents. I give my permission for the above named individuals to participate in the 2019
Jackson County 4-H Pancake Run. I hereby RELEASE FROM LIABILITY, IMDEMNIFY, and HOLD HARMLESS the State of Iowa, Board of Regents of the State of Iowa, Iowa State University, ISU Extension and Outreach, Jackson
County Agricultural Extension District, Jackson County Fair Board, Jackson County Board of Supervisors, and any of the officers, servants, agents and employees of the above-mentioned entities and any event sponsors,
representatives, officials and anyone associated with the 2019 Jackson County 4-H Pancake Run (hereinafter referred to as RELEASEES) for any liability, claim and/or cause of action arising out of or related to any loss,
damage or injury, including death, costs or other expenses or liabilities incurred by me and anyone accompanying me, (including minors I am responsible for during this event), that occurs as a result of my or my child’s
voluntary participation in this program. This release, however, is not intended to release the above-mentioned RELEASEES from liability arising out of their sole negligence.
Participant Name: ________________________________________________________________________________________________________________________
Signature (parent or guardian if under 18): ____________________________________________________________ Date: __________________