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UVI/Queen Mary Highway 5K Walk/Run REGISTRATION FORM Friday, March 23, 2012 @ 6: 00 am Event Information: There are 3 ways in which you can register for the 5k Walk/Run: The 5K Walk/Run will take place from the Sunshine Mall to UVI Albert A. Sheen St. Croix Campus. Registration for UVI students and children is $10.00. Faculty, staff, alumni and other participants’ registration fee is $15.00. Pre-registration for this event begin on March 1 and ends on March 22. The first 100 pre-registered participants are guaranteed a commemorative T-shirt. Breakfast will be provided at the end of the event!!! Prizes will be awarded to the first, second, and third overall male and female; and the first male and female UVI alumni, UVI student, UVI staff and UVI faculty. Transportation will be provided from UVI to the Sunshine Mall. The bus will leave at 5:00 a.m. and at 5:30 a.m. Please make a special effort to be on time should you require transportation. Questions? Email us at ncharle@uvi.edu or call 340-692- 4000. 1. Drop off this registration form to : Necola Charles, UVI Evans Center Room 807 EXACT CHANGE must be with the form. Please place the registration form and the $10.00/ $15.00 fee in an envelope. One entry per envelope please!! OR 2. Mail this form to: Attn: Necola Charles University of the Virgin Islands RR01 Box 10000 Kingshill, VI 00850 Please Note: If registration is mailed the fee must be sent as a money order payable to the University of the Virgin Islands. It is your responsibility to also ensure that the registration fee arrives on/before March 22. 3. Register Online @ www.virginislandspace.org This form can also be located on the www.uvi.edu and www.virginislandspace.org ALL PARTS OF THIS FORM MUST BE COMPLETED TO BE PROPERLY REGISTERED FOR THIS EVENT. Any incomplete forms will not qualify you as a participant in this event. Print Name: ______ _____ _ _____________________ Last First Email address Mailing Address: Facebook Page:_________________________________ Age Group: ( ) Under 20 ( ) 20 – 29 ( ) 30 – 39 ( ) 40 – 49 ( ) 50 – 59 ( ) 60 + T-Shirt Size __________ Gender: ( ) Female ( ) Male Phone # (home) ____ ____ (Cell) ___ _______ Name of my organization or employer: _____ _ ________________________ UVI Alumni ( ) UVI Student ( ) UVI Staff ( ) UVI Faculty ( ) Community Member ( ) Signature: ___ Date: ______ _ ___________ Signature of parent/guardian if you are under the age of 18: Date: ____ ____ RACE NUMBER: WAIVER – RELEASE – STATEMENT OF FITNESS: I take full responsibility for my participation in this event which is conducted in high heat and humidity. I understand that this event will take place on public streets used by automobiles and other vehicles, with limited traffic control. I further release UVI, The V.I. Pace Runners, all sponsors, organizers, and volunteers from all claims resulting from loss, injury, or illness resulting from my participation in this event and give permission to use my name and/or picture, videotape, motion pictures, recordings and other record of this event for legitimate purposes.