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No emails or URLs allowed

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No emails or URLs allowed

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{{ 'STATE/REGION' | translate}}

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The undersigned hereby consents Avita Health System to use photograph(s), video(s), and/or testimonial(s) from the Moving Hearts and Soles 5K Run/Walk on June 25, 2016, for the following purposes:  Newspaper publications, hospital publications, advertising, or any marketing collateral promoting this 5K event or any other wellness activity of Avita Health System.  In consideration of this entry being accepted, I, intending to be legally bound, do hereby, for myself, my heirs, executors, and administrators, waive and release forever any and all claims for damages, including consequential, against Avita Health System, Galion Hospital, City of Galion, Polk Township, Galion Orthopedic Center, event race management, the race director, and all other event sponsors, event committee, and their representatives, successors, and assigns for any and all injuries by me or my child athlete from participating in this event.  I attest and verify that I have full knowledge of the risks involved in this event and am physically fit and sufficiently trained to participate in the Moving Hearts and Soles 5K Run/Walk on June 25, 2016.

{{ 'MUST-AGREE' | translate}}

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  • {{ 'VIEW-IMAGES' | translate }}

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SKU# {{product.sku}}
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{{ 'SUBTOTAL' | translate}} : {{cart.subtotal | currency:"$":currency.decimal}}
{{customFee.description}} : {{customFee.price | currency:"$":currency.decimal}}
{{ 'PROCESSING_FEE' | translate }} : {{cart.fee | currency:"$":currency.decimal}}
{{ 'SALES_FEE' | translate}} : {{cart.totalSales | currency:"$":currency.decimal}}
{{!cart.hasLottery ? ('TOTAL'|translate) : ('TOTAL_CHARGE_AT_CHECKOUT'|translate)}} : {{cart.total | currency:"$": currency.decimal}}

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{{ 'SUBTOTAL' | translate}} : {{cart.subtotalLottery | currency:"$": currency.decimal}}
{{customFee.description}} : {{customFee.price | currency:"$": currency.decimal}}
{{ 'PROCESSING_FEE' | translate }} : {{cart.lotteryFee | currency:"$":currency.decimal}}
{{ 'TOTAL_CHARGE_IF_SELECTED' | translate}} : {{cart.lotteryTotal | currency:"$": currency.decimal}}
{{ 'IF_SELECTED_CHECKOUT' | translate:cart}}

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{{ 'NAME-ON-CARD' | translate }}

{{ 'REQUIRED' | translate }} {{ 'PAYMENT-NAME-MIN-LENGTH' | translate }}

{{ 'CARD-NUMBER' | translate }}
{{ 'EXPIRATION' | translate }}
{{ 'SECURITY-CODE' | translate }}
{{ 'POSTAL-CODE' | translate }}
{{ 'CARD-NUMBER' | translate }}
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{{ 'SECURITY-CODE' | translate }}
{{ 'POSTAL-CODE' | translate }}

{{ 'REQUIRED' | translate }}

{{'SHIPPING-ADDRESS' | translate}}

{{ 'FIRST-NAME' | translate }}

{{ 'REQUIRED' | translate }}

{{ 'ENTER_VALID_EMAIL' | translate }}

{{ 'LAST-NAME' | translate }}

{{ 'REQUIRED' | translate }}

{{ 'ENTER_VALID_EMAIL' | translate }}

{{ 'COUNTRY' | translate }}

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{{ 'POSTAL-CODE' | translate }}

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{{ 'STREET' | translate }}

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{{ 'CITY' | translate }}

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{{ 'EMAIL' | translate }}

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{{ 'ENTER_VALID_EMAIL' | translate }}

{{ 'REGION' | translate }}

{{ 'REQUIRED' | translate }}

{{ 'PAYMENT-INFORMATION' | translate }}

{{ 'NAME-ON-CARD' | translate }}

{{ 'REQUIRED' | translate }} {{ 'PAYMENT-NAME-MIN-LENGTH' | translate }}

{{ 'CARD-NUMBER' | translate }}

{{ 'REQUIRED' | translate }} {{ 'INVALID-CREDIT-CARD-NUMBER' | translate }}

{{ 'EXPIRATION' | translate }}

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{{ 'SECURITY-CODE' | translate }} (CSC/CVC/CVV)

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{{ 'REQUIRED' | translate }}

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