5K Run/1 Mile Walk/ Cardio Fusion Exercise Rain or Shine Inaugural AtlantiCare Walk/Run/Stomp on Pancreatic Cancer Benefiting AtlantiCare’s Treasure the Moment Fund To register by mail, send completed entry form with check or money order payable to AtlantiCare Treasure the Moment Fund to: AtlantiCare Cancer Care Institute, ATTN: DeAnnette Stanton‐Cross, 2500 English Creek Avenue, Bldg. 400, Egg Harbor Township, NJ 08234 1 Mile Pre‐Registration (on line registration closes on September 15th) $25 Saturday, Sept. 17, 2016 5‐K Pre‐Registration (on line registration closes on September 15th) $25 Registration: 7:15 ‐ 8:15am Stomp/Cardio Fusion Pre‐Registration (on line registration closes on September 15th) $25 5K Race: 8:30 am Start 1 Mile Walk/5‐K/Stomp/Cardio‐Fusion (Day of Registration) $30 Sleep‐in Donation $20 1 Mile Walk: 9:00 am Start Donation to AtlantiCare Treasure the Moment Fund Cardio Fusion: 9:00 am Start Our tax identification number is 22‐2148992 Location: AtlantiCare employee Quickcharge® payroll deduction Click Here 2500 English Creek Avenue Team Name (if applicable): Building 400, EHT, NJ First Name: Last Name: For Information Contact: Gender: Age: Emergency Phone #: DeAnnette Stanton‐Cross [email protected] Address: City: State: Zip: TEL: 609‐677‐5763 Email Address: Event gift guaranteed to all entrants who preregister by September 2, 2016 Awards: Overall Team w/Fastest Time (minimum 4 participants) 1st Place Male & Female overall Age categories: 16 & under, 17 ‐ 35, 36 ‐ 54, 55 & Up Click Here to Register Online Waiver and Release You Acknowledge that your attendance at the AtlantiCare Cancer Care Institute’s (hereinafter referred to as “AtlantiCare”) Inaugural Walk/Run/Stomp on Pancreatic Cancer Event, including without limitation, your participation in any of the AtlantiCare programs or activities and your use of AtlantiCare’s equipment, facilities, and events. In consideration of your attendance, you hereby assume all risks of injury which may result from or arise out of your attendance or use of the AtlantiCare’s equipment, activities, facilities, events and you agree on behalf of yourself and your heirs, executors, administrators and assigns fully and forever waive, indemnify, hold harmless, release and discharge AtlantiCare and its affiliates and all their respective officers, directors, employees, agents, successors, and assigns and each of them from any and all claims, damages, demands, rights of action or causes of action, present or future, known or unknown, anticipated or unanticipated, resulting from or arising out of your attendance at or use of AtlantiCare’s equipment, activities, action or cause of action. You acknowledge that you have read this waiver and release and fully understand that it is a waiver and release of any and all liability. Signature: Guardian if 18 or under: Date: Date: