1st Annual Stop the Stigma Field Day Registration Form
EVENT DATE: April 29th, 2017, 10:00am-12:00pm, registration and breakfast starts at 8:30am
BENEFITTING: Stop the Stigma, hosted by Sarkis Family Charitable Foundation
EVENT DESCRIPTION: This family-friendly Field Day event features a morning of fun team-based games and activities
including potato sack races, three-legged races, and more. Teams will consist of 4-6 people. The only rule: have fun!
REGISTRATION: www.ehsfamily.com/charity; Sarkis Family Psychiatry office, 529 NW 60th Street, Gainesville, FL 32607;
or on the day of the event at the registration desk from 8:30a-9:45a.
EVENT LOCATION: Kanapaha Veteran’s Memorial Park, 7340 SW 41 Pl, Gainesville, FL 32606. Ample parking is available
at the park.
Breakfast and coffee will be served prior to the Field Day events. Refreshments will be served after the event.
PLEASE COMPLETE THE FOLLOWING REGISTRATION:
FIRST NAME________________________________LAST NAME________________________________________
DATE OF BIRTH mm/dd/yy _______/_______/________ SHIRT SIZE (CIRCLE ONE) YS YM S M L XL XXL
STREET ADDRESS_____________________________________________________
CITY______________________________________ STATE____________________________ZIP____________
TEAM NAME (optional) ________________________________________________________________________
TEAM MEMBERS: (First name, Last name, DOB, Shirt size)
1.
2.
3.
4.
5.
_____________________________________________________________________ YS
_____________________________________________________________________ YS
_____________________________________________________________________ YS
_____________________________________________________________________ YS
_____________________________________________________________________ YS
ENTRY FEES: Pre-registration: $200/team or $35/person
S
S
S
S
S
M
M
M
M
M
L
L
L
L
L
On-site registration: $250/team or $45/person
***PLEASE NOTE*** NO SHIRT SIZE IS GUARANTEED FOR ENTRIES RECEIVED AFTER APRIL 20th.
COMPLETED REGISTRATION CAN BE MAILED OR DROPPED OFF WITH YOUR CHECK PAYABLE TO:
Sarkis Family Charitable Foundation, 529 NW 60th Street, Gainesville, FL 32607
OR EMAIL COMPLETED REGISTRATION TO: [email protected]
FOR CREDIT CARD PAYMENTS: www.ehsfamily.com/charity.
YM
YM
YM
YM
YM
XL
XL
XL
XL
XL
XXL
XXL
XXL
XXL
XXL
PLEASE READ AND HAVE EACH TEAM MEMBER SIGN THE PARTICIPATION WAIVER BELOW
I know that participating in [or volunteering for] a physical activity is potentially hazardous, and could cause injury or
death. I will not enter and participate unless I am medically able, and by my signature, I certify that I am medically able
to perform this event, and am in good health. I agree to abide by any decision of a Field Day official relative to any
aspect of my participation in this event, including the right of any official to deny or suspend my participation for any
reason whatsoever. I assume all risks associated with participating in this event, including but no limited to: falls, contact
with other participants, the effects of the weather, including high heat and/or humidity, traffic and the conditions of the
field, all such risks being known and appreciated by me. I understand that bicycles, skateboards, baby joggers, roller
skates or roller blades, animals, and headsets are not allowed in the event and I will abide by this guideline. Having read
this waiver ad knowing these facts and inconsideration of your accepting my entry, I, for myself and anyone entitled to
act on my behalf, waive and release the Sarkis Family Charitable Foundation, the city of Gainesville, FL, and all sponsors,
their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event,
even though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver.
Printed Name of Participant*
*Parent or guardian signature required for participants under 18
THANK YOU FOR YOU SUPPORT AND PARTICIPATION!
For questions or additional information, please contact:
Heather Sarkis
Phone: (352) 331-5100
Email: [email protected]
Signature*
Date