1st Annual Run & Remember

March 9, 2013 - 11:00AM

At the

LaVern Gibson Championship Cross Country Course

Hospice of the Wabash Valley’s 1^st Annual Run and Remember

PRINTABLE REGISTRATION FORM

PERSONAL INFORMATION (please print)

Last Name: _________________ First Name: ___________________ Middle Initial: ___________

Address: ___________________________ City: ________________ State: ____ Zip: __________

Date of Birth: __/___/____ Age on Race Day: ____ email address: ____________________________

Phone Number: ____________________ Please indicate your choice of event:

_____ Donation* $___________

EVENT SHIRTS : Shirts guaranteed with pre-registration only.

FOR 5k and 10k PARTICIPANTS: FOR 1 mile fun walk: FOR Fun Run Kids:

Select adult sizes: (men long sleeved dri fit) Select adult sizes (Cotton T-shirt) Select youth sizes (Cotton T-shirt)

S M L XL XXL S M L XL XXL S M L XL XXL

Method of Payment

Check* #______ □ Visa □ MasterCard _______________________ ________ Total Amount Enclosed:

Credit Card No. Exp. Date

$ ______________________

_____________________________________

Signature

*Please make checks payable to Hospice of the Wabash Valley, 400 Eighth Avenue, Terre Haute, IN 47804

All Prices above are for pre-registration through March 1, 2013: Add $5 After March 1, 2013

PLEASE READ AND SIGN BELOW BEFORE SUBMITTING ENTRY

I know that running a road race is a potentially hazardous activity that could cause injury or death. I should not enter and run unless I am medically able and properly trained, and by my signature, I certify that I am medically able to perform this event, am in good health, and am properly trained. I agree to abide by any decision of a race official relative to any aspect of my participation in this event, including the right of any official to deny or suspend my participation for any reason whatsoever. I assume all risk associated with running in this event including, but not limited to: falls, contact with other participants, the effects of the weather, including high heat and/or humidity, traffic and the conditions of the road, all such risks being known and appreciated by me. I understand that bicycles, skateboards, baby joggers, roller skates or blades, animals, and radio headsets are not allowed in the race and I will abide by this guideline. Having read this wavier and knowing these facts, and in consideration of your acceptance of my entry, I for myself and anyone entitled to act on my behalf, waive and release Hospice of the Wabash Valley., its officers and agents, all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event, even though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver. NO REFUNDS. T-SHIRTS OR AWARDS WILL NOT BE MAILED. In addition I agree to pay a $25 replacement fee if I do not return the timing chip assigned to me.

Signature

________________________________________ _________________________________________

Name Date

Signature of parent if under 18

________________________________________ ________________________________________

Name Date

* If you can not run but you would like to donate please list the person you are donating in honor of: ______________________________

Please Fax to 812-232-1893 or mail registration form to:

VNA and Hospice of the Wabash Valley ● 400 8^th Ave Terre Haute, IN 47804 ● 812-232-7611