BRAIN TUMOR ALLIANCE RUN/WALK – DENVER 2015! April 4, 2015 REGISTRANT INFORMATION Last Name First M.I. Street Address Date Apartment/Unit # City State Phone E-mail Address ZIP Circle ONE Event – Please circle the event you would like to participate in 5k Walk/Run Chip Timed $25 - after 03/11/15 $30 5k Walk/Run Not Timed $25 - after 03/11/15 $30 1m Family Fun Walk/Run $25 - after 03/11/15 $30 5k/1 Mile Walk/Run CHILD* (up to 5) $0 Virtual Participant* $25 - after 03/11/15 $30 VOLUNTEER *For those who would like to attend, but are unable to, you can be with us virtually. You will still receive your event T-shirt, can create a fundraising page, and qualify for fundraising prizes. Gender MALE FEMALE Birth Date Circle Shirt Size: Youth Lg Event T-Shirt - We must receive your registration along with payment by 03/15/14 to guarantee that you receive an event T-Shirt. We will do our best to provide event T-Shirt to all participants that register after 03/15/15; however, these will only be available while quantities last and may not be available in your size. *Children up to age 5 do not receive event t-shirts Adult Sm Are you a Brain Tumor Survivor YES Adult Med Adult Lg _____/_____/_____ Adult XL Adult 2XL Adult 3XL NO Team Name:________________________ Although fundraising is not mandatory, it is an important part of the event. We do encourage all participants to fundraise for the event. For information on how to start your own online fundraising page, see the event details at www.BrainTumorAlliance.org – click on the upcoming event tab then “Denver 2015”. .For information, assistance with fundraising, or any other questions, information can be downloaded by visiting http://www.BrainTumorAlliance.org/ or contact us. Registration amount from above $ _____________________ Additional donation in the amount of $ _____________________ Total $ _____________________ CASH T VISA MASTERCARD All donations are tax deductible CHECK CREDIT CARD AMEX DISCOVER #________ #____________________________________________Exp. date____________________ _***PLEASE READ THIS UNCONDITIONAL WAIVER & RELEASE AND EVENT RULES AS THEY HAVE LEGAL & BINDING CONSEQUENCES ON YOUR RIGHTS AND IMPACT YOUR PARTICIPATION IN THIS EVENT. In signing this absolute and unqualified release from all liability, I acknowledge that I understand its intent, and for myself, my heirs, executors, administrators and representatives, do hereby agree and WAIVE, RELEASE, DISCHARGE, HOLD HARMLESS AND PROMISE TO INDEMNIFY AND NOT TO SUE Miles For Hope, their directors, officers, volunteers, agents or trainees , corporate sponsors, volunteers, cooperating organizations and any other parties connected with this event in any way together with their respective successors and assigns (the “Sponsors”), singly and collectively, from and against any blame and liability for any injury, harm, loss, inconvenience, or any other damage of any kind whatsoever, to include Sponsors’ own negligence, which may result from or be connected in any way to my volunteering or participation in the Moving Towards A Cure® Event. This agreement may not be modified orally, and a waiver or modification of any provision shall not be construed as a waiver or modification of any other provision herein or as a consent to any subsequent waiver or modification. I hereby represent that: (1) I am physically capable of participating in this event; (2) that my bicycle, if applicable, and any other equipment I may use are in good working condition; (3) the safekeeping and security of personal property is my responsibility; (4) I will observe all applicable traffic and event rules, and (5) I will wear a helmet, if applicable, and conduct myself in a safe and prudent manner while participating. I acknowledge my voluntary participation, the inherent danger in this event and assume the risk of such participation with the understanding rule violations result in disqualification from the event. I further acknowledge having been provided a copy of the event rules, afforded ample opportunity to read them and have any questions about them answered to my satisfaction. I hereby agree to abide by the event rules as a precondition for my participation. I hereby consent to and permit emergency treatment in the event of injury or illness while participating in this event. I also give permission to Miles For Hope to use my name and any images taken of me during the event in any promotional materials, publications or on the Internet. I also give permission to Miles For Hope to release my name, addresses and phone numbers to any official representative of a team that I have chosen to join. I hereby WAIVE, RELEASE, DISCHARGE, HOLD HARMLESS AND PROMISE TO INDEMNIFY AND NOT TO SUE the Sponsors their directors, officers, volunteers, agents or trainees from any damage I may sustain because of any breach of these representations/acknowledgments or violation of event rules. Notice for our younger walkers or riders: Waivers/releases of walkers and riders under the age of 18 must be signed by a parent or legal guardian and The walker/rider must also be accompanied by an adult (21 or older. I also give permission to have my likeness, without compensation, published on Miles For Hope website social media outlets, and/newsletter. I CERTIFY THAT I HAVE READ THIS WAIVER & RELEASE AND THE EVENT RULES AND UNDERSTAND THEIR SIGNIFICANCE. Print Name: ________________________________________________ Signature __________________________________________________________________ MAIL REGISTRATION FORM, ALONG WITH A CHECK OR MONEY ORDER (ALONG WITH ANY DONATIONS) MADE PAYABLE TO BRAIN TUMOR ALLIANCE TO: BRAIN TUMOR ALLIANCE, 2561 NURSERY RD SUITE D, CLEARWATER, FL 33764 _________________________________________________________________________________________________________________ Signature Brain Tumor Alliance is a 501(c)(3) nonprofit, tax-exemptDate organization designated by the Internal Revenue Code. Our tax identification number is 26-3429074. www.BrainTumorAlliance.org - [email protected] – Phone: 727-781-HOPE(4673) FAX: 727-781-6425