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Registration FormPlease indicate the event you are registering for:
Adults $35.00 3K Walk 5K Run/WalkYouth (13 to 17) $20.00 3K Walk 5K Run/Walk12 and under FREE* 3K Walk 5K Run/WalkFamily (Maximum 2 Adults)* $70.00
* an adult must be on site if participant is under the age of 12
Name:
Address:
City: Postal Code:
Day Phone:
Email:
Company:
Gender: Age: YYYY / MM / DD
Circle your shirt size: Women’s and Men’s - S M L XL XXL Youth S M L (shirt sizes are not guaranteed)
Do you want to fundraise for the CDA? Yes No
Circle your payment option: Visa MC Cheque(cheque payable to the Canadian Diabetes Association)
Card Number:
Expiry: Signature:
Cost: CDA Donation:
Total amount being charged:
Signature: Date:
A registration form and waiver (on back of this form) must be completed for all individuals including children.
Questions? Please contact Rachele Bissonnette at [email protected] or 780-423-5722 ext. 245 for more information.
Mail form and payment to: Canadian Diabetes Association Suite 100, 12220 Stony Plain Road Edmonton, AB T5N 3Y4
or register online at www.runningroom.com
Raise Funds! In addition to walking or running, we encourage you to raise funds in support of the Canadian Diabetes Association. These funds will be used to support Canada’s most renowned scientists and clinicians in their quest for new and innovative developments in the prevention, treatment, and management of diabetes.
Although the research is diverse in its scope, the key aspects remain the same – to improve the quality of life of people living with diabetes and to find a cure.
Clothing Drive! We will be collecting gently used clothing and small household items on the day of the event. All proceeds help support the more than nine million Canadians living with diabetes or prediabetes. Or you can schedule a FREE pick-up at 1-800-505-5525 or diabetes.ca/clothesline
with
TEAM DiAbETEs in
Grande Prairie
Fundraising incentive Prizes!All participants receive a technical shirt. Collect donations to be eligible for prizes!
• Raise$125Your registration fee will be refunded
• Raise$250Receive a Lace Up with Team Diabetes Sports Pouch
• Raise$500Receive a Lace Up with Team Diabetes Backpack
• Raise$1000Receive a Lace Up with Team Diabetes Ipod Shuffle
Plus all finishers will receive a medal!Registration will start at 8:30 am with the Walk/Run start at 10:00 am at the Muskoseepi Park Pavilion, Grande Prairie.
For more information please contact Rachele Bissonnette at [email protected] or 780-423-5722 ext. 245. Register online at www.runningroom.com
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teamdiabetes.ca1-800-BANTING (226-8464)
saturday, August 23 Muskoseepi Park
Walk or Run! Family Fun! Prizes!
Refreshments! Kids Activities!
3K or 5K Walk or Run
Donation Form• Please sign the back of any cheques made out in your name• Please only include donors for whom you are currently submitting funds• Donations over $15 will receive tax receipts for income tax purposes• Please do not mail cash – cheques, money orders, credit card information
are accepted in place of cash. Make cheques payable to The Canadian Diabetes Association.
Thank you for your support and see you at the event!
Run date: Run location:
Name:
Phone:
Address: Associate:
City: Prov.: PC: branch #:
Email:
Name of donor Please print clearly and in full or tax receipt may not be issued Phone number Donation Amount submitted
Tax receipt required?
Cheque # or credit card # and expiry dateAddress City Prov PC
John Sample 1234 Main Street Runville ON M1B 3X2 123-456-7890 $100.00 Yes Cheque #123
Fundraising money/miscellaneous cash donations not requiring a receipt $
Total donations remitted $
Mail collected donations to:Canadian Diabetes Association Suite 100, 12220 Stony Plain Road Edmonton, AB T5N 3Y4
Questions: For more event day information please call Rachele Bissonnette at 780-423-5722 ext. 245 or [email protected]
teamdiabetes.ca | 1-800-BANTING (226-8464)
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Participant Waiver Waiver and Release I know that running/walking a road race is a potentially hazardous activity. I should not enter and run/walk unless I am medically able and properly trained. I realize that the event is physically strenuous; that there may be adverse weather conditions and that there may be vehicles present on the course and at intersections. I nevertheless, wish to compete and assume any and all risks associated with running/walking this event including but not limited to falls, contact with other participants, the effects of weather including heat and/or humidity, the conditions of the roads and the presence of traffic, all such risks being known and appreciated by me. Knowing these facts in consideration of your accepting my entry, I hereby for myself, or for anyone else who may claim on my behalf agree not to sue and waive, release and discharge all persons participating in the operation of this event including without limitations: The Canadian Diabetes Association, The Race Director, all sponsors, their successors and any and all personnel whether volunteer or otherwise, acting on their behalf (the Releasees) for any and all claims, demands, cause of action, damages, or injuries, whether caused by negligence of the Releasees, or by any other cause, which may arise as a result of, or out of my participation in this event. I also indemnify and hold harmless the Releasees from any liability incurred by them and caused by myself. I attest that I am physically fit, and sufficiently trained for this event. I hereby grant permission for the use of my likeness participating in this event without obligation or compensation to me. As part of the Waiver and Release, I acknowledge that I have read and understand all of the above.
signature of participant or parent or guardian required if the entrant is under 18 years of age.
Print name
Thank you for registeringThe Canadian Diabetes Association
sincerely thanks everyone including our volunteers, sponsors, donors and participants.
Lace Up with Team Diabetes events are a great way to spend time with friends and
family while raising money for diabetes. The money raised helps the Association lead the fight against diabetes by helping people
with diabetes live healthy lives while we work to find a cure.
Charitable Number 11883 0744 RR0001
with
TEAM DiAbETEs
