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$25 per person fro

$30 per person o

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COSTUME CONTEST TOP T HREE WINNERS IN THE FOLLOWING CATEGORIES:

INDIVIDUAL COSTUME PARTNER COSTUME GROUP COSTUME

Date: Saturday, October 31

Time: Registration begins at 7 a.m.;

Race begins at 8 a.m.

Location: Augusta Health

Lifetime Fitness Center

5K WALK/RUN

nefiting Patients Supported by the Augusta Health Cancer Services Bridge Fund

WILL BE HELD RAIN OR SHINE Please leave your pets at home for this event

icipants Name: Address:

ail address: Phone #:

cle T-shirt Size: S M L XL Female or Male

Registration Fee before October 1 $25 October 1st - 30th $30 Day of Race

dit Card Information Select Card Type: Name on card:

d Number: Exp. Date:

Make checks out to Augusta Health Foundation. Registration not refundable.

Drop o or mail registration form to: 11 N. Central Ave., Staunton VA 24401,or email it to halloweenrace@newsleader.com

PARTICIPANT RELEASE AND WAIVER OF LIABILITY

Release and Waiver of Liability (the Release) executed on this date,__________________________, by ___________________________________________________________________

f, applicable, in conjunction with _____________________________________, the parent having legal custody or legal guardianship of the Participant, in favor of Augusta Health Care, Inc

rot corporation, its directors, ofcers, employees, and agents (collectively, Augusta Health). The Participant desires to engage in certain activities on the campus of Augusta Health and/or

ties of Augusta Health, as more particularly described below (the Activities). In consideration of Augusta Health permitting the Activities, the Participant hereby freely, voluntarily, and with

utes this Release under the following terms:

elease and Waiver.Participant does hereby release and forever discharge and hold harmless Augusta Health and its successors and assigns from any and all liability, claims, and demands oof nature, either in law or in equity, which arise or may hereafter arise from Participants Activities. Participant understands that this Release discharges Augusta Health from any liability or clacipant, or Participants representatives, may have against Augusta Health with respect to any bodily injury, personal injury, illness, death or property damage that may result from Participanther caused by the negligence of Augusta Health or its ofcers, employees, Participants, agents or otherwise. Participant also understands that Augusta Health does not assume any responsation to provide nancial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness.

ssumption of the Risk. Participant hereby expressly and specically assumes the risk of injury or harm in the Activities and releases Augusta Health from all liability for injury, illness, death age resulting from the Activities.

surance.The Participant understands that except as otherwise agreed to by Augusta Health in writing, Augusta Health does not carry or maintain health medical, or disability instance coveracipant. Each Participant is expected and encouraged to obtain his or her own medical or health insurance coverage.

ther.Participant expressly agrees that this release is intended to be as broad and inclusive as permitted by the laws of the Commonwealth of Virginia and that this Release shall be governpreted in accordance with the laws of the Commonwealth of Virginia. Participant agrees that in the event that any clause or provision of this Release shall be held to be invalid by any court ofdictions the invalidity of such clause or provision shall not otherwise direct the remaining provisions of this release, which shall continue to be enforceable.

gning below, the Participant and, if applicable the parent/guardian, has read, understood, and executed this Release as of the date rst above written.

Participant: ______________________________________________________ Parent/Guardian: __________________________________________

(Signature) (if under 18) (Signature)

Phone: __________________________________________________Address:_________________________________________________________

Email: ________________________________________________________________

Activity Description:________________________________________Activity Date:________________________

(Participant Print Name)

(print name of parent/guardian if under 18)

5K WALK/RUN