The Vascular Birthmarks Foundation
Olivia
before
treatment
Olivia’s Walk for Birthmarks
May 16, 2015 at 10:00am
Neshaminy State Park
3401 State Road, Bensalem, PA 19020
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1 mile Community Walk
Event day registration starts at 9:00am
Free T-Shirt for the first 100 Registered Walkers
Register as a Team or student to receive a discount
Contact: Andria Gottsabend
[email protected] (267) 616-9232
Olivia
after
treatment
REGISTRATION FOR OLIVIA’S WALK FOR BIRTHMARKS
Name: _______________________________________________ Date of Birth______/______/_______ □ M □ F
Address: _____________________________________City: ______________ State: _____ Zip: _______
Phone: ____________________________ E-mail: ______________________________________________
Emergency Contact Name: ________________________________ Phone: __________________________
Team Name:______________________________________ Team Captain:__________________________
Note: Each Team member must complete a separate form and sign waiver below.
Shirt Size: Youth: □SM (6-8) □MD (10-12) □LG (14-16)
Adult: □SM □MD □LG □XL
Requested size contingent upon availability
□
YES, I would like to be a volunteer! Please sign me up for_______________________________
FEES: □ Individual: $15.00 per entrant if registered by May 11th ($20.00 on day of event)
□ Team and/or Student Rate: $10.00 per entrant in a Team of 5 or more ($15 on day of event)
□ Special Family Rate: $30 per family ($35 on day of event). Please list names of family members (Up to 5)
1. ___________________________ 2. _____________________________3. ___________________________
4. ___________________________________ 5. ___________________________________
□ I Cannot Participate in the Walk/Run But Would Like to Sponsor a Child with A Birthmark to Participate :
□ $20.00 Minimum Donation □ Other Amount __________
Athlete/Participant Release: Please Sign and Date (one per walker required):
WAIVER OF LIABILITY: I understand that walking and running in races are potentially hazardous activities. I should not enter a run or walk in the Vascular Birthmarks
Foundation Olivia's Walk for Birthmarks unless I am medically able and properly trained. I agree to abide by any decision of an official relative to my ability to safely
complete the run/walk. I assume all risks associated with participating in this event including, but not limited to falls, contact with other participants or volunteers,
the effects of the weather, and course conditions, all such risks being known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of your acceptance of my application, I, for myself and anyone entitled to act on my behalf, do waive and release the Vascular Birthmarks Foundation,
Neshaminy State Park, the town of Bensalem, PA, the Commonwealth of Pennsylvania, and all other sponsors, their representatives and successors from all claims
and/or liabilities of any kind arising out of my participation in this event even though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver. I also grant permission to all the foregoing to use any photograph, motion picture, recordings, or any other record of this event for any
legitimate purpose.
Signature_____________________________________(If Under 18—Legal Guardian relationship)_____________________
Date ________
SEND COMPLETED FORM AND PAYMENT TO: VBF, PO Box 106, Latham, NY 12110
Method of Payment: □ MasterCard
□Visa
□Discover
□Check(enclosed) payable to Vascular Birthmarks Foundation
Credit Card No. ______________________________Expiration Date: ________ 3-digit Code: ______
Total Amount Enclosed or to be Charged: $ __________
Visit us at www.birthmark.org VBF is an approved 501(3)(c) not-for-profit ▪ Federal Tax ID#16-1515227