Spotlight On Nursing
- October
13, 2007
Web Entry Form -
Please check event: q 4 Mile
Run/Walk q
1 Mile Walk
First name_______________________ Last
name____________________________________
Address______________________________________________________________________
City______________________________________ State______________
ZIP____________________
Phone - day _________________________ Phone - evening
__________________________
E-mail address
________________________________________________________________
Sex: r Male r
Female Age:_____________
T-Shirt size q S q M q L q XL
q XXL
Payment: q
$15.00 No Shirt q
$20.00 Long Sleeve Shirt
q
$13.00 TEAM -No Shirt q $18.00
TEAM -Long Sleeve shirt (team
deadline is October 6)
TEAM NAME: _________________________ TEAM CAPTAIN:________________________
Race Day sign up is $20 per person - no guarantee of shirt or shirt size.
q
I would like to donate an extra
$______ to benefit the Nurses Scholarship Fund
Credit Card r
Visa r
Master Card
Card # _____________________________________________ Exp. Date ________
Signature below will validate charge card. Total amount to be
charged $______
FAX TO: 317-873-5803 - deadline for fax is Tuesday at 5 pm on October 9.
WAIVER (Must be signed)
In consideration of the foregoing,
I, for myself, my heirs, executors and administrators, waive and release any and
all rights and claims for damages I may have against any of the sponsors,
organizers, City of Indianapolis, Tuxedo Brothers, Inc.,
YMCA at the Anthenaeum, their employees, contractors, volunteers for any
and all claims of damages, demands or loss actions whatsoever which may arise as a result
of my participation in this event. I attest and verify that I am physically fit and have
sufficiently trained for the completion of this event and my physical condition has been
verified by a licensed medical doctor. I also understand the unique nature of this running
event. Further, I grant full permission to any and all of the foregoing to use my likeness
for any legitimate purpose whatsoever
______________________________________________________________________