Last Name:___________________________________________
First Name:___________________________________________
Address:______________________________________________
City/State/zip:__________________________________________
Email:_________________________________________________
Birthdate:______________________________________________
Gender:________________________________________________
Phone:_________________________________________________
5K Race Division: (circle one)
Individual Run Individual Walk Team Run
Please list names of team: (if applicable) _____________________
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Please circle shirt size:
x-small small medium large x-large xx-large
Emergency Medical Authorization:
In the event of injury or illness, I give permission to the Angioma Alliance 5k Run/Walk volunteers to obtain emergency medical treatment for me. I agree to pay all reasonable expenses for medical and related treatment obtained for me and further agree that Angioma Alliance is not liable for payment of such
expenses. Adult release, Liability waiver and hold harmless statement for participation in the 2010 Angioma Alliance 5k Run/Walk sponsored by the Brooke Mueller. I understand that there are certain risks involved with participating in the activity identified above. I hereby RELEASE, DISCHARGE AND AGREE TO HOLD HARMLESS ANGIOMA ALLIANCE, AND IT’S VOLUNTEERS, from any and every claim, demand or action of any kind arising due to bodily injury, illness, death and/or property damage resulting from any incident which may occur to me as a result of participating in the 5k activity. This RELEASE, LIABILITY WAIVER AND HOLD HARMLESS STATEMENT does not apply if such injury, death or damage is caused by the willful or reckless action or gross negligence by Angioma Alliance volunteers.
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Signature Date
