Document 6571347

Wickenburg Walks To Boot Breast Cancer
October 19,2014 at Ortega Park in Downtown Wickenburg
7:00 am, Registration, 7:30 am, Opening Ceremony, 8:00 am, Walk Begins
Last Name
(Please Print)
CHOOSE AN EVENT
1 Mle Walk/Run
5K Walk/Run
Sleep in
First Name
I AMA BREAST CANCER SURVIVOR
Mailing Address
**
City
D
#years
SELECT YOUR T-SHIRT SIZE
Adult
Youth
S __XL
M _XXL
L
XXXL
Phone
&FWC
YS
_YM
YL
NoT-Shirt
Team Name
SELECT YOUR CATEGORY
Breast Cancer Survivors $20.00
Youth (12 & under)
$15.00
Adult (Ages 13+)
$25.00
WAIVER AND RELEASE: (Must be signed by al
participants or parent/guardian if under 18 yrs.)
I am a voluntary participant in the October 19, 2014
sponsored by WICKENBURG BREAST CANCER NE'
I am in good physical condition. I know that this event is a
hazardous activity and hereby assume Ml responsibility for
injury or accident which may occur duringmy participation in
event or while I am on the premises of this gseejit
and hold harmless and covenant not to sue the
Wickenburg Breast Cancer Network, Inc. any affiffi
including those individuals organizing this event in Wickenburg,
any race sponsors and their agents, and employees and alt other
persons or entities associated with this event (the Releasees) from
any loss, liability, or claims I may have or which may arise from
my participation in this event including personal injury, or damage
suffered by me or others, whether same be caused by fells, .contact
with other participants and their animals, conditions of the course,
negligence of the releasees or otherwise. Dogs must be leaded at all
times.
Race Entry Fee:
$
Tax deductible donation of:
$15
$25
_$50
$100
Other
No goods or services received for donation.
TOTAL AMOUNT ENCLOSED:
$
PAYMENT METHOD
NO CREDIT CARDS
Check*
Cash
Keep a copy of this form for your tax records.
Checks payable to Wickenburg Breast Cancer Network
(WBCN)
Participant's Name
****
Signature
Date
Return to Team Captain
Bernadine McCollum
H POBox6g
Morristown, AZ 85342-0069
Parent or Guardian Signature (if under 18)
ENTRY FORMS MUST BE RECEIVED M 9/26/14 (S). 4:00 out TO RECEIVE A SHIRT.
it***