HCA 5K Walk/Run Registration Form,          Saturday May 6 2023
Please complete this form for each individual participant.  This form is designed to collect registration for our current HCA parents, students, and staff.  If you have other extended family members or friends who would like to participate, please direct them to our website for general registration information - www.holdenchristianacademy.org/5k 
Sign in to Google to save your progress. Learn more
Email *
HCA Registration Rates
Registration rates vary, please see the list below to know what fee you will be charged.  Please note: No online registrations will be accepted after May 3rd.

Current HCA parents and siblings (age 16+) -    
$20pp before April 8
$25pp before May 5
$30pp race day May 6

Current HCA students and siblings (age 15 and under) -      
$8pp before May 5
$13pp race day May 6

HCA staff and staff kids (age 16+) -                          
$15pp

HCA staff kids (age 15 and under) -
$7

Please note: Your health insurance plan may have a fitness-related activities benefit; check with your specific plan to see if you can get reimbursed!
Name *
Gender *
DOB *
MM
/
DD
/
YYYY
Type of registration *
T-shirt Size (Please note that we will do our best to order the sizes requested, however certain sizes may not be available if you register after April 8, 2023) *
Email *
Phone *
Address *
City *
State *
ZIP code *
Payment (please select how you will pay for the registration):   *
Required
Emergency Contact Information
Participants should list an emergency contact for the day of the race.
Name of Emergency Contact *
Their relationship to the participant *
Phone Number on Race Day *
Age 15 and Younger: Supervisory Information
HCA will not provide supervision, and children age 15 and younger may not be dropped off without an adult.
Name of adult who will be supervising child on race day
Their relationship to the child
Their cell phone for race day
Family Team or Group Team Information
Is this participant part of a team?
Clear selection
Please list the team name here
Race Waiver
I understand that while participating in the HCA 5K Run / Walk  (“Event”), I will be using public areas and facilities where many hazards exist and I am aware of and appreciate the risks that may result. I am also aware that accidents may occur during this event, which could result in serious injury or death. I am voluntarily participating in this event with knowledge of all such risks.In consideration of the acceptance of this registration entry, I ASSUME FULL AND COMPLETE RESPONSIBILITY FOR ANY BODILY INJURY, PERSONAL INJURY, ILLNESS OR PROPERTY DAMAGE THAT MAY RESULT FROM MY PARTICIPATION IN THE EVENT, AND I (ON BEHALF OF MYSELF, MY HEIRS, PERSONAL REPRESENTATIVE AND ASSIGNS) HEREBY RELEASE, INDEMNIFY AND HOLD HARMLESS EVENT STAFF, THEIR AFFILIATES AND THEIR RESPECTIVE OFFICERS, EMPLOYEES, AGENTS AND REPRESENTATIVES, INCLUDING HIRED VENDORS & VOLUNTEERS., FROM (1) ANY AND ALL CLAIMS WITH RESPECT TO LOSSES, INJURIES, AND LIABILITIES, OR DAMAGES (COLLECTIVELY, “CLAIMS”) MADE BY ANY THIRD PARTY ARISING FROM OR RELATED TO MY PARTICIPATION IN THIS EVENT OR (2) CLAIMS THAT I HAVE OR MAY HAVE IN THE FUTURE BASED UPON ANY ACTS OR OMISSIONS, WHETHER KNOWN OR UNKNOWN, RELATING TO, ARISING OUT OF, OR IN CONNECTION WITH THE EVENT, WHETHER THE DAMAGES BE CAUSED BY MYSELF OR BY THE NEGLIGENCE, OF ANY DEGREE, OF THE EVENT STAFF OR OTHER PERSONS OR ENTITIES ASSOCIATED WITH THIS EVENT.I permit and authorize the free use and publishing of my name, image and picture in websites, broadcasts, telecasts and the press as it pertains to this Event.I HAVE CAREFULLY READ THIS WAIVER, INDEMNITY AND RELEASE OF LIABILITY AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT BY SELECTING THE “I AGREE” BUTTON THAT I AM AGREEING TO ITS TERMS, INCLUDING WAIVING LEGAL RIGHTS. KNOWING THIS, I AGREE TO THESE TERMS OF MY OWN FREE WILL.This agreement is intended to be as broad and inclusive as permitted by the laws of the state of Pennsylvania and should be interpreted in accordance with Commonwealth of Pennsylvania law. If any portion of this agreement is held to be invalid, it is agreed that the remainder shall continue to have full legal force and effect.PROVISIONS RELATING TO MINOR PARTICIPANTS IN THE EVENTAs the parent or legal guardian of a minor under the age of 16 seeking to participate in the Event, I hereby permit the named minor (“Minor”), to participate in this Event and I hereby verify that I fully understand, agree to and accept the terms of this agreement on behalf of the Minor. In addition, I certify that I am the parent or legal guardian of the Minor named in this agreement and that I am acting in that capacity.I accept responsibility to inform the Minor that Event Staff and Volunteers have the right to disqualify and dismiss anyone that may cause disturbance during this event. Without limiting any of the foregoing requirements, I also understand that I am solely responsible for facilitating the proper training and instruction the Minor might require to prepare for the Event, including physical preparations, related and applicable traffic rules and general running/walking safety. I understand that a responsible adult over the age of 21 must accompany every Minor at all times during the Event. I understand that my entry fee is not refundable. *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Holden Chapel. Report Abuse