4.01 4.1
RACES&WALKSTotary 5k—11-16-15
RESOLUTION AUTHORIZING ROTARY 5K ROAD RACE/WALK
RESOLUTION NO. ,2015
INTRODUCED BY:
WHO MOVED ITS ADOPTION
SECONDED BY:
WHEREAS, the Glens Falls Rotary Foundation, Inc., has requested authorization from the
Queensbury Town Board to conduct a 5k road race/walk to benefit the Chapman Historical Museum
and the Greater Glens Falls Senior Citizen Center as follows:
SPONSOR Glens Falls Rotary Foundation, Inc.
EVENT 5k Road Race/Walk
DATE Saturday, April 16'', 2016
TIME Approximately 10:00 a.m.
PLACE Beginning and ending at SUNY Adirondack
(Copy of course attached);
NOW, THEREFORE, BE IT
RESOLVED, that the Queensbury Town Board hereby acknowledges receipt of proof of
insurance from the Glens Falls Rotary Foundation, Inc., to conduct a 5k Road Race/Walk within the
Town of Queensbury, and
BE IT FURTHER,
RESOLVED, that the Town Board hereby approves the Glens Falls Rotary to conduct a 5k
Road Race/Walk within the Town of on Saturday, April 16'`, 2016, and
BE IT FURTHER,
RESOLVED, that the Town Board hereby approves this event subject to the Town Highway
Superintendent's approval of the race, which approval may be revoked due to concern for road
conditions at any time up to the date and time of the event.
Duly adopted this 16t`day of November, 2015, by the following vote:
AYES
NOES
ABSENT:
Town of Queensbury Thomas R. VanNess
Highway Superintendent
Highway (518) 761-8212
Department
742 Bay Road—Queensbury, NY 12804 David Duell
Deputy Highway
Phone: (518) 761-8211
Fax: (518) 745-4466 Superintendent
(518) 761-8210
TO: TOWN BOARD
FROM: THOMAS VAN NESS
DATE: NOVEMBER 4, 2015
RE: THE ROTARY 5K ROAD RACE
I have reviewed the request by the Glens Falls Rotary Foundation, Inc., which will hold their
Rotary 5K run/walk event on Saturday, April 16th, 2016 to benefit the Chapman Historical
Museum and the Greater Glens Falls Senior Citizen Center.
Weather permitting, I hereby grant my approval for this event to be held on the following
roadways that are under my jurisdiction: Meadowbrook Road and Cronin Road. The remaining
roadways are not in my jurisdiction and may require additional authorization.
Of..., Re.
Thomas Van Ness
Highway Superintendent
Town of Queensbury
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I-- Saturday, April 16, 2016 it ,1$
r. 41 START TIME:
10:00 AM � { ; �
at SUNY Adirondack Student Center '
Proceeds benefit Chapman Historical Museum E TRACK&�ta-
Greater Glens Falls Senior Citizen Center
Pre-registration: On or before April 8th, 2016 - mail to Glens Falls Rotary, PO Box 2702. Glens Falls, NY 12801 or
register online at www.active.com Entry Fee': ADULT S24 AGE 12 Et UNDER 317 Race Day Registration:8AM to 9,15AM i Registratton'will
ADULT S29 AGE 12 h UNDER S22 Course: One small hill start, then flat and fast! T-shirts: Available for the first 300 be accepted at
entrants[sizes not guaranteed]Awards: Male and Female overall. age groups 1st,2nd,3rd.Team Awards [see page 2]
NAME M F
STREET ADDRESS
7 L'apham Pl ,
CITY STATE ZIP Glens Falls
AGE ON RACE DAY PHONE EMAIL
SHIRT SIZE S M L XL .0
the;
'Checks payable to:Glens Falls Rotary Foundation, Inc. „'�P
I know that running a road race is a potentially hazardous activity.I hereby attest I am medically able and properly trained to run.I agree to abide by any decision
of a race official relative to my ability to safely complete the run.I assume all risks associated with running in this event including,but not limited to,fall,contact
with other participants,the effect of the weather including high or low temperatures,wind,traffic and the conditions of the road,all such risks are being known
and appreciated by me.For safety reasons,headphones should not be used and strollers,roller skates etc are prohibited unless to accomodate the disabled.
Having read this waiver and knowing these facts and in consideration of your accepting my entry.I.for myself and anyone entitled to act on my behalf,waive
and release the Glens Falls Rotary Club.SUNY Adirondack,Town of Gueensbury.Warren County,Washington County,sponsors,volunteers and officials.their
representatives and successors from all claims or liabilities of any kind arising out of my participation in this event.Further,I consent and give permission to
use my likeness and/or voice in photographs,motion pictures,records and/or other record of the Rotary 5K for any legitimate purpose.The Glens
Falls Rotary Club reserves the right to cancel this event without the return of fees due to unforseen circumstances,such as dangerous weather.
SIGNATURE DATE NN. ,,..,.
„r`;{,�t,l,� Ir,
SIGNATURE OF PARENT OR GUARDIAN IF RUNNER IS UNDER 18 YEARS OLD
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Corporate F.. .
Saturday, April 16, 2016
- START TIME: 10:00 AM
at SUNY Adirondack Student Center
Proceeds benefit Chapman Historical Museum E
Greater Glens Falls Senior Citizen Center
All team members must be individually registered by 3:30 AM Race Day.Team Captain is responsible for providing team member names by mail
to race registration address or email to jimm 12804@ ahoo.com by April 12.2016 or to the team registration
9 by 1 Y desk by 8:45 AM Race Day.
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TEAM ENTRY FORM
FEMALE ❑ MALE ❑ MIXED[3[/2M] Li MIXED[2F/3M]
TEAM NAME TEAM CAPTAIN
DAYTIME PHONE
NAME OF CORPORATION 1 ORGANIZATION
EMAIL
TEAM MEMBERS: i
2
3
4
5
TF s;Te an award w l'.also,Ee a�;rarded,f�r the g. . afio ,��dh the ros: art cfoarts croseine the t.nieh ra
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TRACK&FIELD` `:o�ARY
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• DATE: 10/27/2015
CERTIFICATE OF INSURANCE
CERTIFICATE NUMBER: 20151027383881
AGENCY:
ESIX 3 LLC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
d/b/a Entertainment&Sports Insurance eXperts(ESIX) CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES
d/bla Entertainment and Sports Insurance Agency(California) NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
2727 Paces Ferry Road,Building Two,Suite 1500 BELOW.
Atlanta,GA 30339
678-324-3300(Telephone)
678-324-3303(Facsimile)
NAMED INSURED: INSURERS AFFORDING COVERAGE:
USA Track&Field,Inc. Glens Falls Rotary Club INSURER A: Philadelphia Indemnity Ins.Co.
132 East Washington Street,Suite 800 Indemnity INSURER B: Philadel hia
Indianapolis IN 46204 P h Ins.Co.
EVENT INFORMATION:
;Rotary 5K&Corporate Challenge(4/16/2016-4/17/2016)
POLICY/COVERAGE INFORMATION:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE
INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INS TYPE OF INSURANCE: POLICY NUMBER(S): EFFECTIVE: EXPIRES: LIMITS: „ � �
A GENERAL LIABILITY
X Occurrence PHPK1403938 11!1!2015 1111!2016 GENERAL AGGREGATE(Applies Per Event) $3,000,000
12:01 AM 12:01 AM ---—
X Participant Legal Liability EACH OCCURRENCE $1,000.000
DAMAGE TO RENTED PREMISES(Each Occ.) $1,000,000
MEDICAL EXPENSE(Any one person) EXCLUDED
PERSONAL&ADV INJURY $1,000,000
PRODUCTS-COMP/OP AGG $3,000,000
B UMBRELLA/EXCESS LIABILITY
X Occurrence
PHUB517449 11/1/2015 11/1/2016 AGGREGATE(Applies Per $10,000,000
12:01 AM 12:01 AM
EACH OCCURRENCE $10,000,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS:
Coverage applies to USA Track &Field sanctioned events and registered practices, including any directly related activities, such as event set-up and tear-down,
participant check-in and award ceremonies.
The certificate holder is an additional insured as required by written contract or written agreement, but only for liability arising out of the negligence of the Named j
Insureds per the following endorsement.Additional Insured-Certificate Holders(Form PI-AM-002)
The General Liability policy is primary and non-contributory with respect to the negligence of the Named Insureds(Form CG 00 01).
The General Liability policy contains a blanket Waiver of Subrogation as required by contract per Waiver of Transfer of Rights of Recovery Against Others(Form CG
24 04).
Excess policy follows form of underlying General Liability.
CERTIFICATE HOLDER: NOTICE OF CANCELLATION:
Town of Oueensbury Should any of the above described policies be cancelled before the expiration date thereof,
742 Bay Rd notice will be delivered in accordance with the policy provisions.
Queensbury NY 12804
:AUTHORIZED REPRESENTATIVE: