To participate in the 1999 Cincinnati Heart Mini-Marathon, please print out and complete the following registration form.
|
| Registration
Form (please print) |
 |
| Name__________________________________ |
| Address________________________________ |
| City__________________ State____
Zip______ |
| Phone (Day)____________
(Eve)____________ |
| Place of
Employment_____________________ |
Are you a survivor of Heart Disease?
(heart attack, stroke, open heart surgery, angioplasty) ______ |
In consideration of the acceptance of my entry, I for myself,
my executors, administrators, and assignees, do hereby release and discharge the American
Heart Association, Ohio Valley Affiliate, officials, volunteers, and other sponsors for
all claims of damages, demands or actions whatsoever in any manner arising or growing out
of my participation in said athletic event. I attest and verify that I have full knowledge
of the risks involved in this event, and I am physically fit and sufficiently trained to
participate in this event. I consent to the use of photographs, video, film, and sound
recordings of all events for all legitimate purposes. |
Signature of Participant______________________________________
(parent signature required if participant is under 18 years of age) |
Emergency Contact______________________________
Phone Number__________________ |
Entry fee includes a 100 % cotton shirt. Send this form along
with $20 before 3/7/99 ($25 late reg. Fee) to:
American Heart Association
2936 Vernon
Place
Cincinnati, OH 45219
Make checks payable to the American Heart Association. |
I have enclosed an extra $______ as a direct donation to the
American Heart Association. |
Thank You for Carrying the Torch
in the fight against heart disease and stroke! |
