20th Annual Run for Children: 5K Run/Walk to Benefit the Child Life Program at Stony Brook University Medical Center
Date: 08/08/2008 02:44:33 PM
First Name (Please use proper case, this will appear on your name tag!):
Last Name (Please use proper case, this will appear on your name tag!):
Daytime Phone:
Email (
COMPLETE Internet Email Address!!
jdoe@someplace.com):
Verify Email:
Mailing Address (MUST match your billing address on your credit card statement):
Street Address:
Address cont.:
Address cont.:
City:
State:
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Country:
19th Annual Run for Children: 5K Run/Walk to Benefit the Child Life Program at Stony Brook University Medical Center
Gelinas Jr. High School, Setauket, NY
Sunday, October 19, 2008
Registration is required to guarantee a seat. Valid Student/Trainee ID will be required for discounted pricing.
Fees: $17 per person until October 16, $20 day of race.
Number in Party:
Please list first and last names, gender and age for everyone you are registering. Use a new line for every person.
SAMPLE:
John Smith, M, 15
Sally Jones, F, 8
Please read this waiver of liability and check the box to agree to the terms.
In submitting this form for myself (and any participants included above, if he or she is under 18), I understand that I agree to absolve Stony Brook University Medical Center, the Town of Brookhaven, and all sponsors, be they individuals or organizations, singly, or collectively, of all blame for any injury, misadventure, harm, loss or inconvenience suffered in any or the activities associated with the said event. I attest and verify that I am physically fit and have sufficiently trained for the completion of this event, and that my physical condition has been verified by a licensed Medical Doctor. I grant full permission for organizers to use my name, likeness or voice and photographs, videotapes, or quotations from me in accounts and promotions in any medium of this event.
Application Developed by Last Modified 08/08/2008 02:44:33 PM