"White Cane Awareness"
5K Run Registration Form

Date of Birth:    /    /     Age (Day of Race): ___  Sex: ___  Phone: __________  Shirt Size: _____
Last Name: ______________________    First Name: ______________________
Address: _____________________________________________
City: __________________________________State: _______________Zip: _____________
I do hereby release Florida Lions Conklin Centers for the Blind, 405 White Street, Daytona Beach, Florida 32114, or any affiliate of said organizations and International Speedway Corporation, its Officers, Employees, Agents, Subsidiaries, Contractors and Sub Contractors from any and all liabilities for accident or injury which might occur during my participation in the Annual "White Cane Awareness Day" Walk-A-Thon and 5K Run.
Participants under the age of 18 must have this form signed by a Parent or Guardian.

_____________________________________     ______________________________
Runner's Signature and Date                                    Parent or Guardian's Signature and Date

Or you may e-mail the above information to us at: .
100% of all contributions benefit programs of the Florida Lions Conklin Centers For The Blind, Florida Permit #SC00798.

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