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4th Annual |
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Make checks payable to: Broward Health
Foundation Mail to: 5K for a Better Day, 2211 Charleston, Weston, FL 33326 For best results, set page margins to zero before printing. |
___________________________________ ______________________ ________ ( ) ( )
Last Name First Name Age on Race Day Male Female
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Mailing Street Address (Indicate Apt. No. and /or C/O)
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City State Zip Code
__________________________________________________________________________ Email Address ______ ______ ___________ _____________________________________ Birthdate Month Day Year Emergency Contact Telephone Entry Fees Pre-Reg Race Day T-Shirt Size Adults $25.00 $30.00 Small ( ) 19 and Younger $20.00 $30.00 Medium ( ) Kids Fun Run and Youth Mile $5.00 $10.00 Large ( ) X-Large ( ) Check One Run( ) Fitness Walk( ) Wheelchair( ) Kids Fun Run( ) Youth Mile( ) Donation( ) $_____________
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| 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 2009 5K for a Better Day, their representatives, successors and assigns, for any and all injuries sustained by me in this 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. |
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