THE 13 ANNUAL DR. JOHN CAREY MEMORIAL AIDS WALK/RUN

REGISTRATION FORM

Bring this completed Registration Form and your total contribution to the Registration Tent on Septemer 21. Registration will be held from 9 to 11:30 A.M. or register online at www.cleveland.com/AIDSwalk.

YES, I will be participating in (check one): 5K Walk

5K Run

Runners are required to turn in a minimum of $15 at registration to participate. To be eligible for pledging perks and prizes, money must be turned in by September 21.

ALL PARTICIPANTS MUST COMPLETE THIS SECTION

Name

Address

TEAM INFORMATION (if applicable)

City

State

ZIP

Phone (

E mail

Age

Date of Birth

Gender⚫

Male

Female

Required for runners only

ex

2

3

4

>

6

1

8

I am unable to participate. Please accept my donation, enclosed. Checks, made payable to CLEVELAND AIDS WALK RUN, may be mailed to: PO Box 461057, Ceveland, OH 44146-7017.

SPONSOR'S NAME

9.

10.

11

12

13.

14.

15.

SPONSOR'S FULL ADDRESS (PLEASE INCLUDE ZIP)

CLEVELAND

Earn Pledging Perks!

Walkers, runners, and team members can earn perks based on the

total amount raised and turned in by September 21.

$100+

2003 AIDS Walk/Run T-shirt

$150+

2003 AIDS Walk/Run Sweatshirt

AIDS WALK RUN

$250+

Signed CD by pianist Fred Hersch or a copy

of

Marcie Hershman's memoir, Speak to Me

Yes, I am participating as part of an official Team

Team Name

Team Captain

16

participating as part of an official team, the above Team Information must be completed for your team to receive credit.

PLEDGE AMOUNT

RECEIVED

Perks are cumulative. Earn all three. Team members must register separately to be eligible for perks and prizes.

Win Great Prizes!

The top 3 money-raising individuals and teams will receive prize packages. The top 3 finishing male and female runners overall will receive cash prizes. Plaques will be awarded to the top 3 finishing male and female runners in 6 age groups.

Waiver Under 18? Please get a parent's signature!

I, the undersigned, agree to indemnify and hold harmless The Cleveland AIDS Walk/Run, Hermes Sports & Events, the City of Cleveland, all sponsors, agencies, employees or volunteers, from all cost, expense, and liability arising out of my or my child's participation in this event to benefit the Cleveland AIDS Walk/Run. I do hereby waive all claims for damage or loss to my or my child's person or property which may be caused by any act, or failure to act, by Cleveland AIDS Walk/Run, its officers, agents, or employees, arising directly or indirectly from my or my child's participation in this event, and I hereby assume liability for any loss, damage, or other liability from such event.

Participant's signature:

Guardian's signature:

Registration Instructions

Date:

Date:

Convert all cash donations to one check or money order, and have sponsors make checks payable to Cleveland AIDS Walk/Run. Contributions are tax deductible. Returned checks will be proof of donation. Receipts will be available for contributions of $250 or more from one party. Please enter the total you will be turning in on September 21 below, prior to registering.

TOTAL CONTRIBUTION: $

Company matching gift? Yes

If

No

yes, please include matching gift form.

Thank you for your support!