3rd Annual 5K Run and Fitness Walk

Make checks payable to: Pediatric Cancer Center
Mail to: 5K for a Better Day, 2211 Charleston, Weston, FL 33326
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_________________________________ Champion Chip Number ______________________________________________________________________ Employed By ___________________________________  ______________________   ________      (  ) (  ) Last Name                            First Name            Age on Race Day  Male Female ________________________________________________________________________ Mailing Street Address (Indicate Apt. No. and /or C/O) _________________________________   ______________________   _____________ City                                State                     Zip Code               ______   ______   ___________   _____________________________________ Birthdate     Month     Day      Year         Telephone Entry Fees                Pre-Reg      Race Day    T-Shirt Size Adults                 $20.00        $25.00    Small          (   ) 19 and Younger             $15.00        $25.00    Medium         (   )     Large          (   )                                                    X-Large        (   ) Check One     Run (   ) Fitness Walk (   ) Wheelchair (   ) Donation (   )

In consideration of accepting this entry, I, the undersigned, intending to be legally bound hereby, for myself, my heirs, executors and administrators, waive and release any and all rights and claims for injury or damage I may have against the officials or sponsors of the 2008 5K for a Better Day, their representatives, successors and assigns, for any and all injuries sustained by me in said event, including pre- and post-race activities. I attest and verify that I am physically fit, and have sufficiently trained for the completion of this athletic event and competition, which I am voluntarily entering at my own risk. My physical condition has been verified by a licensed medical doctor. Further, I hereby grant full permission to any and all foregoing to use photographs, videotapes, motion pictures, recordings or any other record of this event for any purpose whatsoever.

_____________________________________________ _________________________________________ Signature of Runner Date _____________________________________________ _________________________________________ Signature of Parent or Legal Guardian Date If Under Age 18