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SCHEDULE OF EVENTS

5K WALK / RUN EVENT LOCATION


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.

380 Bellbrook Avenue ♦ Xenia, OH 45385


OFFICE: 937-426-6535 ♦ 24-HOUR CRISIS HOTLINE: 937-426-2334 or 937-372-4552
www.violencefreefutures.org ♦ nicholas.hubbard@violencefreefutures.org

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