The First Annual Stevens Johnson Syndrome 5K Walk/Run
Fundraising Event to Benefit the Stevens Johnson Syndrome Foundation
August 13, 2005
Westminster City Park Promenade
Run Will Begin at 9:00am, Walk Will Begin at 9:10am

Name (last):___________________________, (First) ______________________________________
Address: ______________________________________________________________
City: ______________________________, State: ____________________, Zip: _________________
Age on Walk Day: _____________
Email Address: ____________________________________________________
Phone Number (including area code) : _______________________________
Walk: _________, Run: __________
T-Shirt Size: S_____, M_____, L_____, XL_____
Male: ______, Female: _______

Donation to Walk $25.00 (includes T-Shirt, drinks, and snacks)

( Additional Donations are Greatly Appreciated and Needed )
Total Enclosed: $___________

Make Check Payable To: SJS Foundation
Mail to: SJS Foundation 5K Walk, P.O. Box 350333, Westminster, CO 80035

Release and Agreement: In consideration for being permitted to participate in the SJS 5K Walk, I hereby agree that I, my assignees, heirs, distributors, guardians, and legal representatives will not make a claim against, sue, or attack the property of the SJS Foundation, county of Adams, city of Westminster, State of Colorado, or any sponsor of the SJS 5K Walk, its staff or volunteers (hereafter known as the Promoters), for any injuries or damages arising from my participation in the SJS Foundation Walk. Assumption of risk: I am aware that running or walking a 5k is a strenuous and potentially dangerous activity. With knowledge of the risk involved I herby agree to accept any and all risks of injury or death. I represent and certify that I am physically fit and have sufficiently trained for this event. I have carefully read this official release and agreement, and I understand its content. I am aware that is a release of liability and contract between me and the Promoters of the benefit of the Promoters and all sponsors. I sign it of my own free will. I grant permission for the use of my name and/or likeness to my participation in the SJS Foundation and I waive all rights to any compensation as a result of my likeness. I understand and accept that my entry fee is nonrefundable.

Signature:_______________________________, Date: ________________
(Or signature of parent/guardian of participant if 17 or under day of walk)