Strides for Safety

5K Green Run/Walk
Sunday, September 13, 2009
Aventura Mall
7:00 AM

No Refunds, Exchanges or Transfers.
To print this form, use PRINT option.

Please choose Event:
5 K Run
1 Mile Safety Walk
Date____/____/____

T-Shirt: Small Medium Large X-large

Last Name______________________ First Name_____________________
Sex_____
BirthDate____/____/___ Age______
Phone__________________________ Address_________________________________________________
City____________________________
State______ Zip_____________

With my signature, I acknowledge that running and walking can be inherently stenuous activity and that no event is without risk. I have consulted with my physician regarding my physical capability to participate in this event and am following my physician's advice. I hereby waive all claims against Split Second Timing, The City of Aventura , Aventura Mall, The University of Miami, Ryder Trauma Center, all event sponsors and volunteers , and any personnel functioning with respect to the event for any injury, accidents, or physical conditions I might suffer in this event. I grant full permission for organizers to use my name, likeness, or voice and photographs, videotapes, or quotations from me in accounts and promotions in any medium of this event, and of the activities of Split Second Timing. This permission is perpetual and worldwide.

Signature (Parent/Guardian's Signature if under 18 years) ________________________________________

____ Early Registration Fee before September 7th ..............$20
____ Student Registration before September 7th....................$10
____

_____

Late Registration after September 7th. for everyone........$25

1 Mile Safety Walk Participants. ( T Shirts Given ).........$ 10

Make check payable to:
University of Miami William Lehman Injury Research Center

Mail checks/entry form to:
Split Second Timing
2211 Charleston
Weston, Florida 33326