Go BIG For Parkinson Registration Form

Go BIG for Parkinson’s
10k/5k run, 2k walk Saturday October 15, 2011

Racing to Improve Lives
Registration Form
Please print clearly, one participant per form
_____________________________________________________________________________
First Name Last Name
___________________________________________________________________________
Male/Female Date of Birth (mm/dd/year)
___________________________________________________________________________
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 BIG
PO Box 6036
Flagstaff,AZ 86011-6036
 Or register online at: http://gobigforparkinsons.weebly.com
Pre-registration:Adults 2k/5k/10k= $20/$25/$30

Late Registration:Adults 2k/5k/10k= $25/$30/$35
Kids (12 &Under): $10 for pre-registration and $15 for late registration
On-line registration available till 10/14/11)
(Pre-registration on or before 10/5/11)

(Late registration after 10/6/11 to race day)
*The Go Big Program is a carefully designed and effective Physical Therapy intervention to assist those with
Parkinson’s 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 to PT Student Organization - GO BIG, they may be included with your registration
fee, and mailed together. Mail to: PO BOX 15105 Flagstaff, AZ 86011
 Yes, I would like to make a donation to help individuals with Parkinson’s 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!

RELEASE FORM
THIS IS A CONTRACT WITH LEGAL CONSEQUENCES. READ IT CAREFULLY BEFORE SIGNING.

Participant’s Name:__________________________________________
Event: __Go BIG for Parkinson’s 10k/5k/2k_______________________
Location:__Flagstaff, AZ Northern Arizona University_______________
Date:__Saturday October 15, 2011_______________________________
In 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, or negligence, but also from the action, inactions, or negligence of others.
Further, there may be other risks not known to me, or not reasonably foreseeable, such as disability or death.
 Assume all the foregoing risks and accept personal responsibility for any damages following any such
injury, permanent disability, property damage, or death.
 Release, waive, discharge, and covenant not to sue the State of Arizona, the Arizona Board of Regents,
Northern Arizona University, their officers, employees, and agents, and their heirs, administrators, and
executors, from demands, losses, or damages on account of injury, including death or damage to property,
caused or alleged to be caused in whole or in part by the negligence 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 of Regents, and Northern Arizona University do
not provide medical coverage 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 HAVEREAD THE ABOVE WAIVER ANDRELEASE, UNDERSTAND

THAT I HAVE
GIVEN UP SUBSTANTIALRIGHTS BY SIGNING IT, AND SIGN IT VOLUNTARILY.
Participant’s 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#:_________________
_________________________ __________________________
Participant’s Signature Parent/Guardian if under 18
_________________________ __________________________
Date Date

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Go BIG for Parkinson’s

10k/5k run, 2k walk Saturday October 15, 2011

Please print clearly, one participant per form

 Or register online at: http://gobigforparkinsons.weebly.com

Pre-registration:Adults 2k/5k/10k= $20/$25/$30

On-line registration available till 10/14/11)

(Pre-registration on or before 10/5/11)

 No, I would not like to make an additional donation at this time.

Thank you for your support!

THIS IS A CONTRACT WITH LEGAL CONSEQUENCES. READ IT CAREFULLY BEFORE SIGNING.

In consideration of being allowed to participate in any way in this event I, _________________________

 ACKNOWLEDGE THAT I HAVEREAD THE ABOVE WAIVER ANDRELEASE, UNDERSTAND

Participant’s name (print):_______________________________________________

Mailing Address: ______________________________________________

Work Phone: _____________________ Emergency Phone: __________________

Is this participant covered by health insurance? Yes: ___ No: ___

Health Insurance Company: ______________________________

Policy #: ________________ Group#: ________________ ID#:_________________

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Work Phone: ___ Emergency Phone:

Is this participant covered by health insurance? Yes: _ No: _

Policy #: Group#: ID#:_