Date, Time and Location Saturday, April 25, 2015 • Blanchard Park YMCA, East Orlando 8:00 am: 5k Start (3.1 mi) Entry Fee Non-refundable & non-transferable. Fee based on date received at Central FL FCA Office (Thru April 23rd) (April 24th-25th) On-site 5K Adults: $20 $30 Students: $15 $25 1 Mile Fun Run All Ages $10 $10 Kids Dash (11 and Under) No Registration Required All Categories 5K Run/Jog/Walk (Receive Tech Shirt) Chip Timing for Race Mile Fun Run (Receive T-Shirt) Kids Dash (Receive Participation Award) Awards to follow Race Total Team Participation and Individual (5K) Awards Fax, deliver or mail completed information below, with payment to Central FL FCA 8701 Maitland Summit Blvd Orlando, FL 32810 • 407-644-8292 Festival to follow with: Live Music, Games, Face Painting, Food Trucks and More!! Packet Pick Up: Blanchard Park YMCA Pick-up your race number, shirt, and race information: April 24th 12:00-7:00 p.m. April 25th(Race Day) 6:30 a.m. Restrictions: For safety reasons, baby joggers/strollers, in-line skates, skateboards and dogs will not be allowed in the race. *YMCA Childcare available during 5K Please include all names and ages below FAITH & FITNESS FESTIVAL ENTRY FORM Race: 5K ______ Mile Fun Run _____ Team (If Any) Group/Church/Organization: _______________________________________ Last Name: __I__I__I__I__I__I__I__I__I__I__I__I__I First Name: __I__I__I__I__I__I__I__I__I__ MI ___ Male ____ Female____ Address (street) __I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__ D.O.B. __/__/___ Age on Race Day____ City __I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__I__ State____ Zip Code___________ E-mail_________________________________ Home Phone: ____________________________ Cell Phone: _______________________ ADULT Shirt Size S_____ M ______ L ______ XL ______ XXL ______ YOUTH Shirt Size S______ M ______ L _____ XL _____ Childcare: Name and ages: 1.________________ 2._________________3.__________________4.________________5.______________ Method of Payment: Cash $ ___________ Check #_______________ Charge : Visa _________MasterCard ____________American. EX . __________Discover___________ Card#_______________________________________________________________ Exp. Date:__________/__________CCV Code______ Name as it appears on the card: ____________________________________________________________ Amount enclosed: _________ Billing Address: ___________________________________________________________________________________________________ Total Amount to be charged: _____________________ (Please note an additional 5% processing fee for credit card payments) Send Payments to: FCA ▪ 8701 Maitland Summit Boulevard ▪ Orlando ▪ FL ▪ 32810 ▪ www.centralfloridafca.org (407) 644-8292 or Fax: (407) 644-8912 INCOMPLETE OR UNSIGNED ENTRY FORMS WILL NOT BE ACCEPTED. In consideration of my entry being accepted, I intend to be legally bound, and do hereby, for myself, my heirs, executors, waive and release all rights and claims for damages which may have or which may hereinafter accrue to me against FCA, YMCA, and the sponsors of the event which I am entering, any subsidiary or political division thereof, of their respective officers, agents, directors, representatives, successors, assigns, and sponsors for any and all damages or injuries which may be sustained and suffered by me in connection with my association with entry or participation in the face as is mentioned above. If I should suffer injury or illness I authorize officials of the race to use their discretion to have me transported to a medical facility, and I take full responsibility for these actions. I attest and certify that I am physically fit and have sufficiently trained for the completion of this event. I hereby grant full permission to any and all of the foregoing to use any photographs, videotapes, motion pictures, recordings or any other record of this event for any purpose. Bicycles, baby strollers/joggers, dogs, inline/roller skates, are prohibited. The use of headphones is discouraged. I HAVE READ THE ABOVE RELEASE AND UNDERSTAND THAT I AM ENTERING THIS EVENT AT MY OWN RISK. Signature (if under 18, parent signature required) _________________________________________________ Date _________________