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No emails or URLs allowed

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No emails or URLs allowed

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In consideration of acceptance of this entry form, I/we the below signed, intending to be legally bound, hereby for myself/ourselves, our heirs, administrators and assigns, waive and release any and all claims for damages against The Burke Rehabilitation Hospital, Fast Finishes, any and all sponsors and their representatives, volunteers, and successors and assignees for any and all injuries and/or expenses incurred by me/us at the Burke Heels and Wheels 5K road race to be held on Sunday May 3rd 2015.  I further attest to that I am physically qualified to participate in the race and do not suffer from any major illness that would make my participation a medical risk.    
 

{{ 'MUST-AGREE' | translate}}

{{ 'MUST-AGREE' | translate}}

I hereby authorize the Burke Wheelchair Games and Heels and Wheels 5K to take and use photos and/or video of me during the meet for publicity purposes and/or for use in future programs.  I understand that these photos and/or video may be included in printed publications and/or posted on Burke’s website and social networking sites.

{{ 'MUST-AGREE' | translate}}

{{ 'MUST-AGREE' | translate}}

Beautiful shirt for all preregistered athletes!

{{ 'COUPON-APPLIED' | translate }}

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{{ 'ITEM-FREE' | translate }} * {{ 'MAKE-SELECTION' | translate }}
  • {{ 'VIEW-IMAGES' | translate }}

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SKU# {{product.sku}}
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If you would like to contribute to the good works of the Burke Rehabilitation Hospital, you may do so here. Thank you!


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{{ 'SUBTOTAL' | translate}} : {{cart.subtotal | currency:"$":currency.decimal}}
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{{ 'PROCESSING_FEE' | translate }} : {{cart.fee | currency:"$":currency.decimal}}
{{ 'SALES_FEE' | translate}} : {{cart.totalSales | currency:"$":currency.decimal}}
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{{ 'TOTAL_CHARGE_IF_SELECTED' | translate}} : {{cart.lotteryTotal | currency:"$": currency.decimal}}
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{{ 'PAYMENT-ERROR' | translate}}

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

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{{ 'REGION' | translate }}

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{{ 'PAYMENT-INFORMATION' | translate }}


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

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