5K RUN & WALK FOR AUTISM
Registration FormSaturday September 28, 2013Sommer Center at Bluffton UniversityRegistration begins at 8:00 A.M Walk/Run begins at 9:00 A.M
Please circle one: Run Walk Team Captain________________ Team Name__________Name_____________________________________________ age________ Gender__________Address_______________________________________________________________________E-mail address__________________________________________________________________T-shirt, Shirt Size S M L XLAdvance registration fees: Must be received by August 30, 2013.
Run/Walk pre-registration $15.00 by August 30, 2013 (includes T-Shirt)Race day registration $20.00 (no T-Shirt)
All proceeds go to support activities of the Center for Autism and Dyslexia PTOPlease make checks payable to:The Center for Autism and Dyslexia PTO
2280 Baton Rouge Dr. Lima, Ohio 45805
RUNNING CATEGORYWomen [ ] Men [ ] Girls under 18 [ ] Boys under 18[ ] 60 and over [ ]
In consideration of the acceptance of my entry in the 5K Run/Walk for Autism, myself, my heirs, executors and administrator, waive, release and forever dischargeany and all rights and claims for damages which I may have or which may hereafter accrue to me against The Center for Autism and Dyslexia and any other personsconnected with this event, individually or collectively, from all responsibilities for any injury to person or property during this event on September 28, 2013.
Signature ______________________________________________________________________Guardian Signature, If under 18 __________________________________________