registration for vincent's 5K run/walk |
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| Name: | ____________________________________________ | |||||
| Birthdate: | ____________________________________________ | |||||
| Gender (circle one): |
male |
female |
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| Age on Race Day: | ____________________________________________ | |||||
| Address: | ____________________________________________ | |||||
| ____________________________________________ | ||||||
| City/State/Zip: | ____________________________________________ | |||||
| Phone: | ____________________________________________ | |||||
Email: |
____________________________________________ | |||||
| T-shirt size (circle one) |
Youth L |
Adult M | Adult L |
Adult XL |
Adult XXL | |
| Waiver | I understand that a road race is a potentially dangerous activity and I, the undersigned, assume all risks associated with running or walking in this event and do hereby release and discharge The Vincent DiBerardinis Foundation, Inc., Hillsmere Elementary School, The Annapolis Striders and all sponsors and volunteers from any claims of liabilities of any kind rising out of my involvement in this activity. | |||||
| Signature | ____________________________________________ | |||||
| Parent/Guardian Signature (if under 18) |
____________________________________________ | |||||
| Fees (circle one and submit check) | 17 & under $5.00 |
18 & over $20.00 |
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| Additional donation? | ____________________________________________ | |||||
| TOTAL enclosed? (fees/donations) | ____________________________________________ | |||||
| Make checks payable to: | The Vincent DiBerardinis Foundation, Inc. | |||||
| PRINT this form and Mail registration to: | The Vincent DiBerardinis Foundation, Inc. Laura DiBerardinis 303 Cedar Lane Annapolis, MD 21403 |
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| Questions?: | Laura DiBerardinis 410.280.6226 laura@vincentdfoundation.org |
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