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Print this page or pick up an application at the Clubhouse, Hastings Fitness Center,  UCO Office, or Century Village Realty Office.

5th Annual Century Village WPB, Florida 5K Run/Walk

Monday February 20, 2017 at 9:00am

Starting and finishing at Clubhouse

Proceeds will go to Century Village Honor Flight.

 

    Runner (  )        Walker (   )        Volunteer (  )     Donor (  )          Check #_________ 

 

 

Name _________________________________________________________________

 

Address _______________________________________________________________

 

Home Phone ___________________________________________________________

 

E-Mail Address _________________________________________________________

 

 

WAIVER: I know that participating in the 2017 Century Village 5K Run/Walk and related events is a potentially hazardous activity.  I agree not to enter and participate unless I am able and properly trained.  I am voluntarily entering and assume all risks associated with participating in this event, including but not limited to, falls, spills, contact with vehicles, other participants, spectators or others, the effects of weather, including heat and/or humidity, or traffic, and the conditions of the course or other areas of the event, all such risks being known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of your acceptance of this application, I, for myself and anyone entitled to act on my behalf, do hereby waive and release The United Civic Organization of Century Village, West Palm Beach, Florida, West Palm Beach Recreational, Facility Incorporated, and any sponsors or volunteers of this event from all present and future claims and liabilities, known and unknown, arising out of my participation in this event. I grant my permission to all of the foregoing persons and entities to use or authorize others to use any photographs, motion pictures, recordings, or any other record of my participation in the event for any legitimate purpose without remuneration.

 

I attest that I am physically able and sufficiently trained to participate in this event and take full responsibility of myself.

 

Signature: _____________________________________________________Date:___________________

 

Return Application with check in amount of $10. ($15.00 after 2/17/17) Payable to: UCO

 

Main Club House Lobby between 1 PM and 3 PM,

Tuesdays & Thursdays, 1/31 -  2/16/2017

 

OR

 

mail to: United Civic Organization

2102 West Drive

West Palm Beach FL 33417

 

Tee shirts provided by CV Real Estate will be distributed upon receipt of check

For further information call: (631) 889-2614 or

email: ucowalk@gmail.com

 

 

NO CASH OR CHECKS OUTSIDE OF THE UNITED STATES ACCEPTED

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