For every $1 cash donation at the event, your name will be entered into our opportunity drawing! Join us on Facebook: Brain Injury Alliance of Utah Brain Injury Alliance of Utah Presents: The 20th Annual 5K Run, Walk, & Roll Join us Saturday May 16th 2015 at 8:00 a.m. start time Liberty Park: 600 East 1300 South, Salt Lake City, Utah Register Online at www.runreg.com/run-walk-roll or MAIL-IN REGISTRATION Form Below **Day of registration to open at 6:30am** Join us for a Day of Fun, Entertainment, and Prizes! Please visit our donation page at https://www.runreg.com/run-walk-roll Each donor will be entered into our opportunity drawing on the day of the race For an ADA accommodation, contact George Gehling at 801-716-4993 Please mail this registration form to: BIAU 5280 S. Commerce Drive #E190, Murray, UT 84107 For Information Call: 801-716-4993 or 800-281-8442 Name Age (required) Address City E-Mail State Phone Are you a Traumatic Brain Injury Survivor? Please Check One: Run Zip Team Name YES Walk Gender NO Wheelchair Recumbent Bike (must wear helmet) Note: Runners will be awarded to 1st, 2nd, 3rd place Men’s and Woman’s – Wheelchair and Recumbent Bike users will be awarded 1st, 2nd, and 3rd place Registration Fee: Donation: $30 $10 $25 (Early Bird, Until May 1st) $20 $50 $100 $250 How did you hear about the 5K? Other: Or visit our donation page at https://www.runreg.com/run-walk-roll T-shirt size: SM MED LG XL XXL XXXL Child Med Child LG Note: T-shirts only guaranteed to those who register Prior to May 1st RELEASE & WAIVER (Please read & sign): In consideration and acceptance of this entry, I hereby, for myself, my heirs, my executors and administrators, waive any and all rights and claims I may have against the sponsor, coordinating group, and any individuals associated with the event, or their connection with said event. I represent that I am in proper physical condition to participate in this race and understand the risks associated with this event including but not limited to falls, contact with other participants, the effects of weather and the conditions of the road. I understand that I am solely responsible for my own safety while traveling to and from or participating in the event. By signing this form, I acknowledge that I have read and fully understand my own liability and do accept all responsibility. Signature Parent/ Guardian signature if participant is under 18 years old Date