Second Wind of St. Louis, Missouri

I AM NOT ABLE TO PARTICIPATE BUT WOULD LIKE TO DONATE

SECOND WIND LUNG WALK ENTRY FORM ONLINE
Saturday October 16, 2010 Forest Park St Louis Mo

PARTICIPANT:

PHONE:

ADDRESS:

CELL:

CITY:

STATE:

ZIP:

E-MAIL:

TEAM NAME:

TEAM CAPTAIN:

SHIRT SIZE

I WILL PARTICIPATE IN:

5K Race
5K Walk
1 Mile Fun Walk
I'm Just Here For The T-Shirt

ARE YOU A:

Recipient
Care Giver
Friend
Professional

HOW DID YOU LEARN ABOUT LUNG WALK:

Fill Out This Section If A Minor Is Participating: (if not, skip this section and go to AGREEMENT)

I give permission for my child who is under age 18 to participate in the Second Wind Lung Walk.

YOU ARE THE CHILD'S:

Parent
Guardian

Adult's Name:

Today's Date:

AGREEMENT

Second WindLung Walk Waiver: By clicking agree I hereby waive all claims agains Second Wind Lung Transplant Association, Road Runners Club of America, St Louis Track Club, Team Spot Tees, sponsors and/or any other personnel and agencies connected with this event for any injury I might suffer in this event. I grant full permission for Second Wind to use photographs of me and quotations from me in legitimate accounts and promotions of this event.

I Agree