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Alumni Event Tickets
Reservation Form
Fallen Soldiers 5K Run/Walk
Saturday, October 10, 2015

Personal Information
First Name:
Last Name:
Home Phone #:
() - *
Cell Phone #:
() -
* Class Year:
* State: * Zip Code: *

T-shirt Type:
Men Women Children

T-shirt size:
X-Small Small Medium Large X-Large
XX-Large (adult only)

Date of Birth:
Male Female
Are you a veteran or service member?
Yes No
Additional Contribution @ $10 per person*
Additional Contribution @ $25 per person*
Additional Contribution @ $50 per person*
Additional Contribution @ $100 per person*
Fallen Soldiers 5k Run/Walk Registration @ $25 per person*
Total: $  
By submitting this registration form, I agree to the following Release and Waiver of Liability: I, the Undersigned, understand that there are certain dangers, hazards, and risks inherent to this activity, which also could include serious or even mortal injuries and property damage, and that Western Illinois University does not assume responsibility for any such personal injuries or property damage.

In consideration of the opportunity to participate, I agree to assume all risks and responsibilities surrounding participation in the activity, and in advance, release and forever discharge, waive, and covenant not to sue Western Illinois University, its Board of Trustees, employees, and/or any students acting as employees in their official and individual capacities, from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature whatsoever which Participants may have or which may hereafter accrue to the Undersigned, arising out of or related to any loss, damage, or injury, including but while in, on, or upon the location where the activity occurs or is being conducted. I further state that I have sufficiently trained for and am in proper physical condition to participate in this event. My signature below represents my acknowledgement of the risks and my voluntary agreement to these terms.

I further grant authorization for the free use of my name and/or photographs, video tapes, motion pictures or recordings of my participation in the event.

I will not bring any pets, rollerblades, skates, skateboards, or scooters to the event.
Initial here to agree to liability waiver   

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