8/9/2019 Go BIG for Parkinson
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Go BIG for Parkinsons10k/5k run, 2k walk Saturday October 9,
2010Benefiting persons with Parkinsons Disease
Registration Form
Please print clearly, one participant per form
First Name Last Name
Male/Female Date of Birth (xx/xx/xxxx)
E-mail address T-shirt size (all sizes are adult: S M L XL)
Race starts on NAU South Campus/ Dubois Grassy Bowl (Pine Knoll
Dr.) 10k event begins at 8:30a.m, followed by 9:00am 2k/5k start.
Registration and check-in starts at 7:30 a.m. Mail completed
registration form, waiver, and non-refundable check or money order
(no cash please) payable to:
NAUPTSA-GO BIGPO Box 6036Flagstaff, AZ 86011-6036
Or register online at: http://gobigforparkinsons.weebly.com
Pre-registration: Adults 2k/5k/10k= $20/$25/$30Late Registration:
Adults 2k/5k/10k= $25/$30/$35Kids (12 &Under): $10 for
pre-registration and $15 for late registration(Pre-registration on
or before 09/27/10)(Late registration after 09/27/10 to race
dayOn-line registration available till 10/6/10)
*The Go Big Program is a carefully designed and effective
Physical Therapy intervention to assist those with Parkinsons
Diseases (PD) in
achieving better quality of life through better quality
movement. Proceeds from donations for the 10k/5k run and 2k walk
will be placed in
a scholarship fund. Individuals with PD in Flagstaff will be
awarded scholarships from this fund, which will allow them to
participate in
the Go Big Program, an opportunity to dramatically enhance their
quality of life.
You may choose at this time, or the day of the race, to make a
donation to this scholarship fund. Please make checks payable
toNAUPTSA- GO BIG, they may be included with your registration fee,
and mailed together.
Yes, I would like to make a donation to help individuals with
Parkinsons at this time, in the amount of $.
No, I would not like to make an additional donation at this
time.
Thank you for your support!
8/9/2019 Go BIG for Parkinson
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RELEASE FORMTHIS RELEASE IS A CONTRACT WITH LEGAL CONSEQUENCES.
READ IT CAREFULLY BEFORE SIGNING.Participants Name:Event: Go BIG
for Parkinsons 10k/5k/2kLocation: Flagstaff, AZ Northern Arizona
UniversityDate: Saturday October 9, 2010In consideration of being
allowed to participate in any way in this event I,
Acknowledge and fully understand that I will be participating in
activities that may or may not involve risk of serious injury,
permanent disability, property damage and/or death. These risks may
result not only from my own actions, inactions, ornegligence, but
also from the action, inactions, or negligence of others. Further,
there may be other risks not known to me, ornot reasonably
foreseeable, such as disability or death.
Assume all the foregoing risks and accept personal
responsibility for any damages following any such injury,
permanentdisability, property damage, or death.
Release, waive, discharge, and covenant not to sue the State of
Arizona, the Arizona Board of Regents, Northern ArizonaUniversity,
their officers, employees, and agents, and their heirs,
administrators, and executors, from demands, losses, ordamages on
account of injury, including death or damage to property, caused or
alleged to be caused in whole or in part by thenegligence of any
person or otherwise, for myself and my spouse, if any, and our
heirs, successors, and assigns.
Understand that the State of Arizona, the Arizona Board
ofRegents, and Northern Arizona University do not provide
medicalcoverage to a participant if injured while participating in
the event described above or attendant activities. Any medical
costs
incurred as a result of this activity will be my financial
responsibility.
ACKNOWLEDGE THAT I HAVE READ THE ABOVE WAIVER AND RELEASE,
UNDERSTAND THAT I HAVEGIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
AND SIGN IT VOLUNTARILY.
Participants name (print):
Mailing Address:
State: Zip: Home Phone:
Work Phone: Emergency Phone:Is this participant covered by
health insurance? Yes: No:
Health Insurance Company:Policy #: Group#: ID#:
Participants Signature Date
Parent/Guardian signature is participant is under 18 Date
