Proceeds will benefit the IU Health Arnett Foundation’s Area of Greatest Need Fund. This fund is utilized for specific needs as they
arise to improve the overall health and wellness of our patients and community. This fund can be utilized for equipment, expansion
of services and programs, training and education, or for general use. It is vitally important to have these funds for needs that do not
meet the specific areas of giving we have established. As a public charity and supporting organization, the mission of the Foundation
is to support IU Health Arnett providers and programs in improving the health of patients and the community through innovation
and excellence in care, education, research and service. To learn more about the foundation, go to iuhealth.org/arnettfoundation.
Packet Pick-up:
Friday, May 8, 2015 – 3 pm – 6 pm
Main entrance of IU Health Arnett Hospital
5165 McCarty Lane, Lafayette, IN
Race day Start Time:
Saturday, May 9, 2015 - 9 am at IU Health Arnett Hospital
Day of Race Packet Pickup and Registration:
Saturday, May 9, 2015
7 am – 8:30 am at IU Health Arnett Hospital
Make Checks payable to: IU Health Arnett Foundation
2550 Greenbush Street, Lafayette IN, 47904, ATTN: Cheryl Suter
_____________________________________________________________________________________
First Name
Last Name
_____________________________________________________________________________________
Address
City
State
Zip Code
_____________________________________________________________________________________
Phone Number
Email Address
Date of Birth
______________________________________________________________________________________________
Emergency Contact
Relationship
Phone Number
Sex: (Circle one) Male Female
Shirt Size: (Circle one) YM
Early registration fee (on or before April 15):
$25.00
After April 15 Including Day of Race (Shirt not guaranteed):
$30.00
YL S
M L XL
2XL
Age 6 and under no charge
I will:
_____ walk
_____run
Are you an employee of IU Health? (Circle one) Yes No If yes, what department? ______________
Release and Waiver:
In consideration for the opportunity to participate in the 5K Run/Walk activities being held by IU Health Arnett on May 9, 2015, I on behalf of myself, my heirs,
successors and assigns and my estate or minor child for which I am parent or legal guardian hereby release, discharge and waive any and all claims against Indiana
University Health Arnett and its affiliates and other sponsors of this event including their employees, volunteers and agents for any and all claims for injury, loss
including death or damage of any kind to any person or property that I may incur or my minor child may incur as a result of participation in this event.
I attest and verify that I have full knowledge of the risks involved in this event and I am solely responsible to determine whether I or my minor child is physically
fit and sufficiently trained to participate. If I require medical treatment during this event, I hereby consent to authorize medical personnel to provide such care as
they deem necessary.
The undersigned further acknowledges that he or she has carefully read the above Release and Waiver and knows and understands all of the contents thereof and
further understands and agrees that by signing this release he or she gives rights and assumes the risk of injury or property damage and signs this Release and
Waiver as their free and voluntary act.
In consideration of acceptance of the above entry, I hereby waive and release any and all rights and claims for damages and/or injuries suffered during the event
against Tri-N-Run, IU Health Arnett and/or any sponsor or official of this run. I grant permission to all of the organizers/sponsors of this event to use any
photographs, motion pictures, recordings, or other records of this event for any legitimate purpose. I declare that I am physically fit to participate in this event.
Signature: _____________________________________________________ Date: __________________
This release must be signed by all participants and/pr by the parent or guardian if the participant is under 18.
Print Name: ____________________________________________________