1. You can a registration form here.

For every $1
cash donation at
the event, your
name will be
entered into our
opportunity
drawing!
Join us on
Facebook: Brain
Injury Alliance
of Utah
Brain Injury Alliance of Utah Presents: The 20th Annual 5K Run, Walk, & Roll
Join us Saturday May 16th 2015 at 8:00 a.m. start time
Liberty Park: 600 East 1300 South, Salt Lake City, Utah
Register Online at www.runreg.com/run-walk-roll
or MAIL-IN REGISTRATION Form Below
**Day of registration to open at 6:30am**
Join us for a Day of Fun, Entertainment, and Prizes!
Please visit our donation page at https://www.runreg.com/run-walk-roll
Each donor will be entered into our opportunity drawing on the day of the race
For an ADA accommodation, contact George Gehling at 801-716-4993
Please mail this registration form to: BIAU 5280 S. Commerce Drive #E190, Murray, UT 84107
For Information Call: 801-716-4993 or 800-281-8442
Name
Age (required)
Address
City
E-Mail
State
Phone
Are you a Traumatic Brain Injury Survivor?
Please Check One:
Run
Zip
Team Name
YES
Walk
Gender
NO
Wheelchair
Recumbent Bike (must wear helmet)
Note: Runners will be awarded to 1st, 2nd, 3rd place Men’s and Woman’s – Wheelchair and Recumbent Bike users will be awarded 1st, 2nd, and 3rd place
Registration Fee:
Donation:
$30
$10
$25 (Early Bird, Until May 1st)
$20
$50
$100
$250
How did you hear about the 5K?
Other:
Or visit our donation page at https://www.runreg.com/run-walk-roll
T-shirt size:
SM
MED
LG
XL
XXL
XXXL
Child Med
Child LG
Note: T-shirts only guaranteed to those who register Prior to May 1st
RELEASE & WAIVER (Please read & sign): In consideration and acceptance of this entry, I hereby, for myself, my heirs, my executors and administrators,
waive any and all rights and claims I may have against the sponsor, coordinating group, and any individuals associated with the event, or their
connection with said event. I represent that I am in proper physical condition to participate in this race and understand the risks associated with this
event including but not limited to falls, contact with other participants, the effects of weather and the conditions of the road. I understand that I am
solely responsible for my own safety while traveling to and from or participating in the event. By signing this form, I acknowledge that I have read and
fully understand my own liability and do accept all responsibility.
Signature
Parent/ Guardian signature if participant is under 18 years old
Date