Name : __________________________________________

1. ATHLETIC TRAINING 5K Run for Disabled Sports USA Date:Sunday, October 12th, 2014 Location: Student Center PatioTime: 9 AM with registration beginning at 8AMPrice: $12.00 for Rowan Students- Staff$15.00 for Non-Rowan Participants. Checks/Donations made out to the Chuck Whedon Scholarship Cash is also accepted. For more information please contact Alejandro Arenas at (609) 331- 7588 or at arenas41@students.rowan.edu ********* Please Return this Form with Payment ******** Name: __________________________________________ Email Address: ___________________________________ Student/Non-Student: ____________________________ Cash/Check:_________ Total Amount: ______________ Date of Birthday: __________ Age: ____ Gender: M__ F__ **First 50 participants registered receive free T-Shirt!** Adult shirt size (circle one): XS S M L XL XXL Child shirt size (circle one): S M L XL Waiver I understand participating in this race is potentially hazardous. I understand the risks associated with participation in this event such as falls, contact with other participatns, and effects of weather. Having read this waiver I understand the accepting of my entry into the Rowan Athletic Training 5k Run/Walk event. I grant permission to all of the foregoing to use any photographs, videos, and any other record of this event for any legitimate purpose. Signature: _____________________ Date: ________ Signature: _____________________ Date: ________ (Parent/Guardian if under 18 years of age)