12th ANNUAL
WISH
HOSTS
LETS HELP FIND A CURE
9 hole (5K) Breast Cancer walk/run
IRONWOOD at Anthem CC, Saturday, Oct. 5, 8:00 a.m. Check In / Registration 7:00–7:45 a.m. Start 8:00 a.m. 9 (5K) Hole ❑ Walk ❑ Run Circle Shirt size: Youth: L, Adult: S M L XL XXL Cost: $20 per adult, $10 11—18, Children under 10 free (no shirt provided) Pay by Check: Payable to TEAM W.I.S.H. ARIZONA, attach to this form & return to the Community Center or either of the Country Club Fitness Centers or contact Dy Mogan at dricemogan@cox.net Pay by Credit Card: ❑ Visa ❑ MasterCard Card #:___________________________________ Exp. Date:______________Sec #___________ Name on card (if different):_________________________________________________________ Signature:_______________________________________________________________ _________
Register by September 14 to receive a shirt. (shirt will be given at event) Only 1 name per registration form please.
Last Name____________________________First Name _________________ Age (if child)_______ Mailing Address __________________________________________________________________ City __________________________________________ State_________ Zip_________________ E-mail ______________________________________ Phone_____________________________ ❑ I cannot participate but would like to donate $ ______________ NO PETS, BICYCLES, SKATEBOARDS, SKATES, SCOOTERS, etc. STROLLERS are permitted. Walk Waiver and Release: I understand that my consent to these provisions is given in consideration of the acceptance of this registration and for being permitted to participate in this event. I am a voluntary participant in this event and in good physical condition. I know that this event is a potentially hazardous activity and I on behalf of myself, my heirs, successors, assigns, executors, administrators and any others acting in my name or on my behalf hereby assume full and complete responsibility for any loss, damage, injury or accident which may occur during my participation in this event or while on the premises of this event, and I hereby release and hold harmless and covenant not to file suit against Team W.I.S.H. officers, directors, members, agents, successors and assigns, any walk sponsors and their agents and employees, and all other persons or entities associated with this event (the “releasees”) from any loss, liability or claims, damages or expenses (including attorney’s fees) I may have arising out of my participation in this event, including personal injury or damage suffered by me or others, whether same be caused by falls, contact with participants, conditions of the course, negligence of the releasees or otherwise. If I do not follow all the rules of this event, I understand that I may be removed from the event. I give my full permission to Team W.I.S.H. and their sponsors and corporate sponsors to use my photograph, videotapes, or other recordings of me that are made during the course of this event.
Signature of participant (parent or guardian if under 18)
Date