Burn Injury Awareness Walk Safety Education Fair and Picnic Registration Form Sunday, June 7, 2015 Check-in: 11:30 a.m. Walk start time: 12 p.m., Safety Education Fair and picnic immediately following the walk Place Route Parking Admission Wiard’s Orchard, 5565 Merritt Road, Ypsilanti 1.5 mile non-competitive walk On-site and free of charge Includes lunch, t-shirt and many fun activities for all ages • Trauma Burn Center rate (for staff or former staff and their family members, also for past patients and their family members): o On or before May 1:  Adults = $15  Children 12 and younger = $5 o After May 1:  Adults = $25  Children 12 and younger =$10 • General admission rate: o On or before May 1:  Adults = $25  Children 12 and younger = $10 o After May 1:  Adults = $30  Children 12 and younger =$15 Registration Required for all participants. Register online by visiting www.biaw.traumaburn.org using a credit card or by completing and returning this flyer with a check payable to the University of Michigan Trauma Burn Center. Registration deadline: May 16, 2015 (May 1 for discounted rate) First Name: _____________________________Last Name: _________________________________________ Parent or legal guardian (s) attending (required for attendees 17 years old and younger): _________________________________________________________________________________________ Address: __________________________________________________________________________________ City, State, Zip: _____________________________________________________________________________ Phone Number: ____________________________________________________________________________ Email Address: _____________________________________________________________________________ Current Age: _________________________ T-shirt size: _________________________ Special accommodations or dietary needs: ______________________________________________________ I would like more information about supporting the Trauma Burn Center (optional) Please complete and mail this form with a check payable to the University of Michigan Trauma Burn Center to University of Michigan Trauma Burn Center Attention: Kate Stricker 1500 E. Medical Center Drive, UH-1C435 Ann Arbor, MI 48109-5033 Event information: www.biaw.traumaburn.org; phone: 734-232-3814; email: [email protected]