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5K walk / RUN OCTOBER 17, 2009 EVENT LOCATION John Bryan State Park 3790 State Route 370 yellow spring, OH 45387 8:30 am 9:30 am 10:00 am Registration Begins Warm Up Walk / Run Begins Pre-Register with the minimum donation to receive a walk t-shirt. I (my child) waive and release, for myself, my heirs, executors and administrators, any and all rights and claims for property damage and personal injury, including death
5K walk / RUN OCTOBER 17, 2009 EVENT LOCATION John Bryan State Park 3790 State Route 370 yellow spring, OH 45387 8:30 am 9:30 am 10:00 am Registration Begins Warm Up Walk / Run Begins Pre-Register with the minimum donation to receive a walk t-shirt. I (my child) waive and release, for myself, my heirs, executors and administrators, any and all rights and claims for property damage and personal injury, including death
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5K walk / RUN OCTOBER 17, 2009 EVENT LOCATION John Bryan State Park 3790 State Route 370 yellow spring, OH 45387 8:30 am 9:30 am 10:00 am Registration Begins Warm Up Walk / Run Begins Pre-Register with the minimum donation to receive a walk t-shirt. I (my child) waive and release, for myself, my heirs, executors and administrators, any and all rights and claims for property damage and personal injury, including death
Copyright:
Attribution Non-Commercial (BY-NC)
Formati disponibili
Scarica in formato PDF, TXT o leggi online su Scribd
John Bryan State Park 8:30 am 9:30 am Registration Begins Warm Up 3790 State Route 370 OCTOBER 17, 2009 Yellow Springs, OH 45387 10:00 am Walk/Run Begins
Pre-Register with the minimum donation to receive a Walk T-Shirt
T-SHIRT SIZE: S M L XL 2X Participants Waiver
In consideration for allowing me (my child) to compete in ______________________________________________________________
the 5K walk / run, I, the undersigned, intending to be Emergency Contact Name Phone Number legally bound, waive and release, for (my child) myself, $20.00 Individual Pre-Registration (per participant) my heirs, executors and administrators, any and all rights Pre-Registration by mail postmarked by 10/14/09. All pre-registered and claims for property damage and personal injury, entries include Goody Bag and Walk T-Shirt. including death, which I (my child) representatives, successors and assignees, arising from my participating $15.00 Teams of 5 or More Registration (per participant) in this event. I verify I have full knowledge of the rigors of All team members must complete the registration form and submit this race and the risk involved in participation, and I am together listing their team name above. (child is) physically fit and have (has) sufficiently trained $25.00 Day of Event Registration (per participant) to compete in this event. I realize medical support for this Event Day Registration (Please complete and bring with you). All event event will consist of primarily volunteer medical personnel day registered entries include Goody Bag and Walk T-Shirt (if available). prepared to administer first aid-type assistance along the race course and at the finish line. I (on behalf of my child) Enclosed is additional money raised $ ___________ hereby grant permission to Family Violence Prevention Center and its sponsors to use all information submitted I cannot attend, but please accept my donation $ __________ in my application and my photograph, video tape, motion I have contacted my company about a matching gift. picture, recording and any other record of this event including pre-race and post-race publicity. Note: Please make checks payable to: Family Violence Prevention Center _______________________________________________________________________ ____________________________________________________ Signature of participant (if a minor, please obtain signature of parent or guardian) __________________________________ Mail or fax this form to: Visa / Master Card Number Family Violence Prevention Center ____________________________________________________ Signature of guardian (if participant is a minor) __________________________________ Attn: Sara Holbrook Expiration Date 380 Bellbrook Avenue ____________________________________________________ Xenia, OH 45385 __________________________________ Phone: 937-426-6535 Date Authorization Signature Fax: 937-376-8529 Print more registration forms online at www.violencefreefutures.org or register by phone.