4.05 4.5
RACES&WALKS\Rotary 5k—11-21-16
RESOLUTION AUTHORIZING ROTARY 5K ROAD RACE/WALK
RESOLUTION NO. ,2016
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 its annual 5k road race/walk to benefit the Under the Woods
Foundation and the Warren-Washington Association for Mental Health as follows:
SPONSOR Glens Falls Rotary Foundation, Inc.
EVENT 5k Road Race/Walk
DATE Saturday, April 15t'', 2017
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 Queensbury on Saturday, April 15t'', 2017, 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 21St day of November, 2016,by the following vote:
AYES
NOES
ABSENT:
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SaturdayApril 152017rdiisprvir` °Flatl$fsh ,
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41"axml, Is. h :3 START TIME10:00
AM10,
als
[ at_SUNY Adirondack Student Center
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II ;e•etars er t. oods g a:° r USA
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Pre-registration: On or before April 7th, 2017 - mail to Glens Falls Rotary, PO Box 2702, Glens Falls NY 12801 or
register online at www.active.com Entry Fee':ADULT$25 AGE 12 &UNDER$17 Race Day Registration: 8AM to 9:15AM
ADULT S30 AGE 12&UNDER S22 Course: One small hill start,then flat and fast!T-shirts: Available for the first 300
entrants[sizes not guaranteed]Awards:Male and Female overall,age groups 1st,2nd,3rd,Team Awards[see page 2]
NAME M F
STREET ADDRESS
CITY STATE ZIP
AGE ON RACE DAY PHONE EMAIL
SHORT SIZE S M L XL
'Checks payable to:Glens Falls Rotary Foundation,.Inc.
I know that nnnirg a road race is a potentially hazardous activity I hereby attest I am medically able and properly trained to nm.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,fa4 contact
with other participants.the effect of the weather including high or low temperatures,wind,traffic and the conditions of the mad,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 accommodate the disabled
Having read this waiver and knowing these facts and in consideration of your accepting my entry.t for myself and anyone entitled to act lin my behalf,waive
and release the Glens Falls Rotary Club,SUNY Adirondack.Town of Queensbury.Warren County,Washington Candy 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 andlor 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 unforeseen circumstances,such as dangerous weather. Y",,,�ilitHalt ds ''p ,___,:,..:-;:- .
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SIGNATURE DATE l l ; ;+a :; ,
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SIGNATURE OF PARENT OR GUARDIAN IF RUNNER IS UNDER 18 YEARS OLD rl"!!`; iing a ,I' N v i' -' i,
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SUNYADIRONDACK 2T�RNAT% - •
-
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! 1 DATE: 11/9/2016
CERTIFICATE OF INSURANCE i
CERTIFICATE NUMBER!20161109481326
'AGENCY: '�— 1 — -
iI
ESIX 3 LLC 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
1 dibMa Entertainment 8 Sports Insurance eXperts(ESIX) i CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES
I d/b/a Entertainment and Sports Insurance Agency(California) 1 NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES I
2727 Paces Ferry Road,Building Two,Suite 1500 � BELOW �
Atlanta,GA 30339 ! i
678-324-3300(Phone),678-324-3303(Fa) I
NAMED INSURED: 1 INSURERS AFFORDING COVERAGE:
USA Track&Feld,Inc Glens Falls Rotary
132 East Washington Street,Suite 800 INSURER A Philadelphia Indemnity Ins.Co.MAIC#.18058
Indianapolis IN 46204 i INSURER B:Philadelphia Indemnity Ins.Co.NAIC#.18058
I
I EVENT INFORMATION:
I Rotary 5k Corporate challenge(4/15/2017-4/16/2017)
i POLICY/COVERAGE INFORMATION: I
1 THE POLICIES OF INSURANCE USTED 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 1
I INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.AGGREGATE I
kILIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSITYPE OFINSURANCE: }POLICYNUMBER(S)ki EFFECTIVE: 1 EXPIRES: !LIMITS:
1 A j GENERAL LIABILITY
I X Occurrence IPHPK1569618 i11f1/2016 111/1/2017 GENERAL AGGREGATE(Applies Per Event) $3,000,000
+, 11201 AM 112:01 AM
! X Participant Legal Liability i EACH OCCURRENCE $1,000,000
I I I DAMAGE TO RENTED PREMISES Each Occ
! ( ) $1,000,000
1
I i 1 MEDICAL EXPENSE(Any one person) EXCLUDED
i PERSONAL&ADV INJURY $1,000,000
! I i i PRODUCTS-COMP/OPAGG $3,000,000
B UMBRELLA/EXCESS LIABILITY
X Oc UITence
1PHUB561340 111/1/2016 111!112017 i EACH OCCURRENCE $10,000,000 i
— 1 11201 AM .1201 AM
1 1 AGGREGATE(Applies Per Event) $10,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/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,1
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 i
Insureds per the following endorsement Additional Insured-Certificate Holders(Form PI-AM-002) i
The General Liability policy is primary and noncontributory 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.
1
. 1
CERTIFICATE HOLDER !NOTICE OF CANCELLATION: 1
Town of Queenbury I Should any of the above described policies be canceled before the expiration date thereof,
742 Bay Rd i notice will be delivered in accordancevriN the policy provision i
QueensburyNY 12804 !AUTHORIZED REPRESENTATIVE: 1
i I
I