Ananias Inc. – LA PATHS
Proudly Presents
Walk for HIV/AIDS Awareness Saturday, June 25, 2011 8:00 a.m. until 12:00 p.m. Clyde Fant Parkway – The Walking Trail From Riverview Park to Stoner Boat Launch end at Festival Plaza– 5mi Register Today One person per registration form. Please print clearly and complete the entire form as applicable. Send completed form to: Ananias Inc. - LA PATHS, 1612 Fairfield Ave., Shreveport, LA 71101. 1. YOUR INVOLVEMENT 2. GENERAL INFORMATION First Name:_________________________ MI:__________ Last Name:____________________________ Address:______________________________________________________________________________ City:______________________________ State:_______________ Zip Code:_______________________ Date of Birth:_______________ Age __________ Home Phone: ( ) __________________ Other Phone: ( ) ____________________ E-mail Address:___________________________________________________________ T-Shirt Size (for completion shirt that will be distributed at the end of the 5K): S M L XL 2XL Parent/Guardian Signature if under 18:____________________________________ 3. REGISTRATION FEE Please submit your non-refundable registration fee with this registration form. Fees are $15 for an individual walker or $10 for a team walker. Please make check or money order payable to Ananias Inc. Registration deadline is June 20, 2011. For questions or additional information, please call (318) 227-9010. In consideration of my being admitted to enter the Walk for HIV/Aids Awareness, I, for myself, my heirs and assigns, executors and administrators, do hereby forever release and discharge Ananias Inc.- LA PATHS and any other sponsors, their employees and agents, of and from any and all claims or demands for damages of liability in any manner arising out of participation in such event. I certify that I have prepared myself for this event and that I am in adequate physical condition to complete the event in which I have entered. I agree to follow all rules of this walk, and to permit myself to be removed from the walk if in the opinion of Ananias Inc. – LA PATHS my continuing would endanger my health.