Sunday, May 3, 2015 - Clinics - Center for Excellence in Disabilities

iASD 5K Run & Family Fun Walk
Hazel Ruby-McQuain Riverfront Park
Sunday, May 3, 2015
Benefitting the intensive Autism Service Delivery (iASD) Clinic at WVU CED
REGISTRATION FORM
Race (check one):
Timed 5K Run -10am
Family Fun Walk -1pm
Name_________________________________________________________________________
Gender:
Male Female Age: _______ ( as of 5/3/15)
Phone: ______________________ Email Address: __________________________________
Adult T-Shirt Size:
Small
Medium
Large
XL
Youth T-Shirt Size:
Small
Medium
Large
XL
2XL
3XL
4XL
Mailing Address: ______________________________________________________________
City, State, Zip: _______________________________________________________________
In case of an emergency, please notify: ____________________________________________
Relationship: ______________________
Phone: ___________________________________
Waiver- In consideration of acceptance of this entry, I waive any and all claims for injuries or damages which
may result from my participation, or from the participation of the minor that I am signing for in the iASD 5K
Run & Family Fun Walk. Any and all claims are waived for myself, my heirs and assigns. iASD, the sponsors
and their agents or representatives, will assume no obligation for injuries or damages that may be incurred
during the duration of this event.
Contestant Signature: __________________________________________________________
Parent or Guardian Signature: ___________________________________________________
(Required if participant is under 18 years of age)
If registered by April 15th:
• $30/per participant
• $15/WVU Students (with
University ID)
All registrations at race $35/per
participant.
Children 12 & under walk
for free, but do not receive
t-shirt. Additional t-shirts can
be purchased for $10 each if
ordered by April 15th. Deadline
to order a t-shirt as part of
registration is April 15th, t-shirts
are available on limited basis
after that date.
Please make checks payable to: WVU Foundation memo line: 2V602
For more information, call 304-293-4692 x 60646 or email
[email protected]
Register online by credit card
at www.clinics.cedwvu.org/
autism or mail completed
registration form and check to:
Attn: Miranda Smalley
Center for Excellence in
Disabilities
959 Hartman Run Rd
Morgantown, WV 26505