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Community Health Center of Branch County

2013 Happy Heart Run Family Registration

SATURDAY, SEPTEMBER 7, 2013

5K Run/Walk
1 Mile Fun Run

EVENT TIMES:
7:00 a.m. - Registration begins, CHC Main Parking Lot, Coldwater, MI
7:40 a.m. - Start of 1 Mile Run
8:00 a.m. - Start of 5K Run/Walk
Waiver: In consideration of acceptance of my entry, I, for my heirs, personal representatives, and administrators, release and for-ever discharge the Community Health Center of Branch County, Happy Heart Run, race director, race committee, race organizers, and any sponsors of this event of all liabilities, claims, action, damages, costs or expenses which I may have against them arising out of my participation in this event. I certify that I am physically fit and able to participate in this event, and I have not been advised otherwise by a qualified medical person.
Consent to Photograph: I hereby authorize the Community Health Center of Branch County to take photographs, videotapes, computer images or other images of me as is desired. I further permit that such may be produced, published, or republished for any purpose deemed fit to be in the interest of medical study and education, research, knowledge, public relations, marketing, or similar purposes.
  Last Name
  First Name
  Address
  City, State, Zip
  Telephone
  Email Address
  Sex Male     Female    
  Age on Race Day
  Select Race 5K Run Walk     1 Mile Run    
  T-Shirt Size
Free T-Shirts for those registered before 8.23.13
Fees
  Family Registration $40 Early Bird Registration (before 8.23.13)     $45 Registration (after 8.23.13)    
Additional Family Members
  Name
  Sex Male     Female    
  Age on Race Day
  T-Shirt Size
  Name
  Sex Male     Female    
  Age on Race Day
  T-Shirt Size
  Name
  Sex Male     Female    
  Age on Race Day
  T-Shirt Size
  Name
  Sex Male     Female    
  Age on Race Day
  T-Shirt Size
Billing Information
* Amount of Payment
Format: 45.67 (Include decimal and cents. Do not use a dollar sign.)
$
* Card Number
* Expiration Date
* Card Code Verification Number
The three digit number on the back of your card. (Four digit code on the front of American Express.)
* Email Address
* Billing Postal or Street Address
* Billing City
* Billing State
* Billing Zip Code
5 digit zip code