5K/Fun Run Registration Form
  • 5K & Fun Run Registration Form

    One form per participant
  • Participant Information

  • Date of Birth*
     - -
  • Gender*
  • Format: (000) 000-0000.
  • Parent/Guardian Information (for participants under 18)

  • Format: (000) 000-0000.
  • Emergency Contact 

  • Format: (000) 000-0000.
  • Race Day Info 

  • Staying for Lunch? (Lunch is included in the fee for all registered participants.)*
  • PARTICIPATION & MEDICAL RELEASE

    While we make every effort to provide a safe and pleasant environment for every camper who attends Camp Assurance, we do require that this participation agreement be read, filled out, signed, and dated by all campers (or their parent/guardian if under the age of 18) who wish to participate in activities at Camp Assurance.


    Although Camp Assurance has taken reasonable steps to provide equipment and skilled employees so you or your child can participate in activities for which you/he/she may not be skilled in, we do remind you that these activities are not without risk. Certain risks cannot be eliminated due to our camp’s rural setting and without destroying the unique character of those activities. The same elements that contribute to the character of these activities can be cause of loss or damage to your property, accidental injury or illness or, in extreme cases, permanent trauma or death. We do not want to frighten you or reduce your enthusiasm for these activities, but we do think it is important for you to be informed and know in advance about inherent risks.

     


    With full knowledge, I accept full responsibility for any injury or accident that may occur to myself or my child while participating in Camp Assurance activities. I give permission for myself or my child to attend and participate in activities that occur at Camp Assurance. These activities may include, but are not limited to, swimming, canoeing, zipline, archery, riflery, paintball, strenuous activities, and competitive games.


    I understand that for promotional or marketing purposes, Camp Assurance reserves the right to use any audio, video, and/or photography of guests or campers participating at Camp Assurance facilities.


    I, on behalf of myself, my children, my assigns and my estate, agree to release and hold harmless Camp Assurance, its officers, board, agents or employees, for any and all claims for injuries, causes of action, or liability related to my or my child’s participation in any activity occurring at Camp Assurance. This release does not apply to intentional and/or willful acts of misconduct by Camp Assurance or any of its officers, board, agents or employees. By signing this document, I acknowledge that if anyone is hurt or property damaged during my or my child’s participation in these activities, I and/or my child may be found by a court of law to have waived any right to maintain a lawsuit against Camp Assurance on the basis of any claim which has been released herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and agree to be bound by its terms.


    I understand that my personal insurance will provide primary coverage for medical aid and that Camp Assurance will provide excess coverage. IN CASE OF MEDICAL EMERGENCY, I hereby give permission to the physician selected by the camp director or his agent to hospitalize, secure proper treatment for, and order injection, x-ray, anesthesia, or surgery for myself or my child as named previously. (Please notify the camp if this participant has been exposed to any communicable disease during the two weeks prior to camp attendance.)

  • Confirmation

    BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

  • Date*
     - -
  • AMOUNT YOU ARE PAYING ONLINE TODAY: Payments may also be sent by mail to Camp Assurance, PO Box 18, Georgetown, IL 61846. Please note that you are not registered until payment has been received. Be sure to scroll to the bottom and click submit. Thank you!

    Categories:All
    All
    5K Options
    Fun Run Options
    Virtual Participant Options
    Optional Add-Ons
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                              5K Options
                              5K includes T-shirt (by Apr 16)
                              $30.00$30.00
                                
                              5K no T-shirt available (after Apr 16)
                              $30.00$30.00
                                
                              Fun Run Options
                              Fun Run with Shirt (by April 16)
                              $20.00$20.00
                                
                              Fun Run NO Shirt Included
                              $5.00$5.00
                                
                              Virtual Participant Options
                              Virtual 5K with T-Shirt (by April 16)
                              $30.00$30.00
                                
                              Virtual 5K No T-Shirt available (after April 16)
                              $10.00$10.00
                                
                              Optional Add-Ons
                              5KAdd On: T-Shirt (by April 19)
                              $20.00$20.00
                              Size Quantity
                              S
                              M
                              L
                              XL
                              XXL
                              Youth S
                              Youth M
                              Youth L
                              Youth XL
                                
                              5K Add On: Kid Lunch Ticket

                              ages 6-12

                              $6.00$6.00
                                
                              5K Add On: Adult Lunch Ticket
                              $8.00$8.00
                                
                              Total
                              $0.00$0.00

                              Payment Methods

                              creditcard
                              After submitting the form, you will be redirected to Apple Pay to complete the payment.
                              After submitting the form, you will be redirected to Google Pay to complete the payment.
                              After submitting the form, you will be redirected to Cash App Pay to complete the payment.
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