Online Event Registration

Second Annual 5K Walk/Run For Life - August 28, 2010
If you are participating to fundraise as a team, each member must fill out their own entry form and note the same team name.

GENERAL CONTACT INFORMATION

Name:
Email:
Phone #:
Gender:     Male Female
Address:
City:
State:
Zipcode:

EMERGENCY CONTACT INFORMATION

Contact Name: Contact Phone:

EVENT INFORMATION

You are registering as a participant volunteer  

T-shirt Size: S M L XL XXL XXXL Child

If participating as team, are you the Team Leader? yes no

Team Name:

I AM PARTICIPATING IN HONOR / MEMORY OF:

I am particpaiting in honor of:

I am participating in memory of:

Are you a cancer survivor?* Yes No     *Cancer survivors participating in this event will receive a distinct T-shirt

Waiver and Indemnification Agreement

I understand that participating in the Barnes Foundation Walk for Life includes an element of risk for me. I should not participle unless I am physically able and properly conditioned. I agree to abide by any decision of an event official relevant to my participation in the event and I further agree that event officials may authorize necessary emergency treatment for me. I also understand that vehicles, spectators and other traffic may be present along the course and I assume the risk of participating under such conditions and any others that may arise. I further assume any and all risks associated with participating in this event, including, but not limited to, injury, illness, falls, contact with spectators, other participants, effects of the weather including temperature extremes, and the surface conditions of the event path, all such risks being understood by me. I agree to abide by all rules of the event.

Having read this waiver and knowing these facts, and in consideration of this acceptance of my entry, I hereby for myself, my heirs, executors, administrators and anyone else who might claim on my behalf, covenant not to sue, and waive, release and discharge the Barnes Foundation, Professional Medical, Inc., International Direct, the Village of New Lenox, event officials, volunteers, and any other sponsors, suppliers, agents, employees or other personnel in any way assisting or connected with this event from any and all claims or liability of any kind whatsoever arising out of my participation in this event, even though the liability may arise out of negligence or intentional acts or omission on the part of the persons or parties named in the waiver. I further understand that by participating in this event, I agree that the Barnes Foundation or any sponsors may use my name or pictures of me for publicity or promotional purposes without any liability or obligation to me.
I have read and agree to the terms of the Waiver and Agreement  



YOUR INFORMATION IS SECURE!
The information you supply will only be used to respond to inquiries, or to supply you with requested information on event details or updates.