I attest and verify that I have full knowledge of the risks involved in the event and that I am physically fit and suffi
10k Run - $30…………………….$___________ Early-Bird - $25 (before 8/31/10)..$___________ Day-of Registration - $35………..$___________ 5k Run/Walk - $20……………….$___________ Early-Bird - $18 (before 8/31/10)..$___________ Day-of Registration - $25…..........$___________ Total……….…………………….$___________ Entry fees include a technical t-shirt, two tickets to the first show of the 2011 Season, a goodie bag, entry to refreshment area, traffic support, and course aid. Day-of registrants not guaranteed a shirt. 10k registrants will receive two extra tickets.
Total payment by: Check/Money Order VISA Discover American Express
MasterCard Cash (In Person Only)
Card Number ___________________________________________________
First Name
___________________________ __________________________ Mailing Address _______________________________________________________ City
Entry fee is NON-REFUNDABLE/NON-TRANSFERABLE for any reason including but not limited to illness and personal emergency. All events will take except in cases of severe weather. *For security, please include your CVV number. This is the three-digit code following the credit card number in the signature line on the back of a VISA, MasterCard, and Discover card. For American Express, the four digit CVV is on the front of the card just above the raised numbers.
State
ZIP
____________________________ ___________ ___________ Home Phone (____) _____-___________
Age on Race Day (October 30,2010) _________
Male
Female
Birth Date (MM/DD/YYYY) _____/_____/__________
Expiration Date _____________________ CVV* ________________ X_____________________________________________________________ (Cardholder’s Signature)
Last Name
T-Shirt Size (Unisex Adult) Sm Med Lrg XL XXL (Please add $2 to registration)
Email Address _______________________________________________________ How did you hear about the 2010 Highway to Hale ? ______________________________________________________
WAIVER: In consideration of participation in this event, I for myself, my heirs, executor and administrators, waive and release any and all rights and claims against the Hale Center Foundation for the Arts and Education and all its subsidiaries, Cody and Cody LLC, the City of Orem, volunteers, and all sponsors, their representatives, officers, employees, agents, and successors as a result of my participation in the events of the Highway to Hale 5k & 10k Race/Walk to be held October 30, 2010. I hereby agree to abide by the rules of the race and realize that disqualification may result from any infraction. All rulings by the race judge or race director are final. I agree that I have sole responsibility to know the course beforehand and will not hold any of the aforementioned parties responsible should I neglect to follow the course and be disqualified. I attest and verify that I have full knowledge of the risks involved in the event and that I am physically fit and sufficiently trained to participate in this race. I authorize the administration of first aid and/or treatment rendered in case of any emergency. I understand that any photographic recording of myself is the property of the Hale Center Foundation for the Arts and Education and I authorize its use in connection with this event.
Signature___________________________________________ Parent’s Signature (if under 18) _____________________________________ Date __________/__________/_____________
Please bring this form with payment to the Box Office or mail it to: 225 West 400 North, Orem, UT 84057 All mail-in entries must be received by Wednesday, October 27, 2010
PLEASE PRINT LEGIBLY
