AN event by the

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					                                                       AN event by the
        Cameron County &District Attorney’s Office—Domestic violence unit
                          Along with the DA’s Sword & Shield, a Non-Profit Organization

                                                      5th Annual
        Victory over violence 5K Run/walk
                                                     Saturday, April 9, 2011


                           Registration form
                                        Please fill out completely. Please print.

This event will begin and end at Louie’s Backyard, South Padre Island, Texas. The run/walk will begin promptly at 8:00 a.m. Please
arrive early. Registration will begin at 7:00-7:40 a.m. Participants may pickup their packets at the day of the event or at the DA’s
Office on Friday, April 8, 2011 by 5pm. For other information or questions, contact Korina Barraza at (956) 459-4157.

PARTICIPANT INFORMATION:
Full Name

Address, City, State & Zip

Phone #                                                    Age          Sex          Preferred T-Shirt Size
                                                                                        S       M        L          XL
Email

Special considerations (ex: pets, baby strollers, bike, etc.)

WAIVER STATEMENT:
   I recognize that weather, traffic, road conditions, contact with other runners or other conditions may make this walk/run
hazardous. I waive any and all claims for myself, my administrator and my heirs against all officials, sponsors and
organizations, executors of the State of Texas, Texas Highway Department, County of Cameron, City of South Padre
Island, the District Attorney’s office, the officials and any and all volunteers connected with the Victory Over Violence 5K
Run/Walk, for injury or illness which is directly or indirectly a result from my participation in this event. I hereby release
and hold harmless the aforementioned parties. I attest that I have full knowledge of the risks involved in this event and I
am physically fit and sufficiently trained to participate in this event. Further, I grant the City of South Padre Island, the
Cameron County District Attorney’s Office, and the D.A.’s Sword and Shield permission to use my photograph or any
recording of my participation in this event for any legitimate purpose. I understand that registration is final and there are
no refunds.

SIGNATURE: __________________________________                                 DATE:___________________________
                  (Parent or guardian if under 18)

                                        Select One:     □ 5K                     □ 1K

PAYMENT INFORMATION:
Fee:                                                                                $25.00
*Student with valid school ID                                                       $10.00
Group—Identify Group: ________________________________
(10 member minimum—Elementary, Middle & High School only)                          $ 5.00 per member
TOTAL amount enclosed:                                                             _______

Make check payable to DA’s Sword and Shield – 5K. Return form and payment by mail to P.O. Box 2299, Brownsville,
Texas 78523, or by hand delivery to the D.A.’s office at 964 E. Harrison St.—4th Floor, Brownsville, Texas 78520.

                **Medal Award Divisions (Male & Female): 17 & Under; 18-35; 36-54; 55-older**
                               **Prize: Overall 1st, 2nd & 3rd Place Winners**

				
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