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Name _____________________________________

Address ___________________________________

City _________________State _____ Zip ________

Phone _____________________________________
                                                                                                 Fun run &
Adult T-shirt Size (circle one) S M L XL XXL                                                                          About Doctors & Lawyers for Kids

Email ______________________________________
                                                                                                                With the formation of Doctors & Lawyers for
                                                                                                                Kids, Louisville is added to a growing list of
Signature of Parent/Guardian if under 18                                                                        communities in which physicians and attor-
                                                              Saturday, August 20, 2011                         neys join forces to improve the health and
Level One: $25 (after Aug. 1 -$35)                            Thurman Hutchins Park                             well-being of low-income families and chil-
(includes registration for the 5k fun run/walk, goodie                                                          dren. One of more than 80 medical-legal
bag and access to event entertainment)                        3734 River Rd. (River Rd. & Indian Hills Trail)
                                                                                                                partnerships around the country, the program
Level Two: $35 (after Aug. 1 -$40)                         Benefitting Doctors & Lawyers for Kids               offers free legal assistance to indigent pa-
(includes t-shirt, registration for the 5k fun run/walk,                                                        tients in the areas of housing, disability, pub-
goodie bag and access to event entertainment)              Registration begins at 8 a.m. Race 9 a.m.            lic benefits, family law, education, utilities,
Children under 12 free.                                                                                         employment, bankruptcy and child abuse/
*All participants raising more than $75 will be eligible
for great prizes!                                                                                               With initial funding from the Louisville Bar
                                                                                                                Foundation and the Children’s Hospital
Level Two participants must register by 8/1 to be guar-                                                         Foundation, attorneys from the Legal Aid
anteed a 2011 Walk T-shirt. Register online at                                              nt                                                                          eve                     Society have begun working part-time in
                                                                                  led                           donated space within the Children and Youth
                                                                             -fil        an        ke
                                                                        fun ture anca es                        Project, an indigent care clinic operated by
Payment Information:                                                is
                                                                  Th ill f ea ea t p               us
                                                                                               ho ist,          the University of Louisville Pediatrics. “
{ }Check (payable LBC)                                                 w        n-        c e        ur
                                                                           -ca         un         cat !
{ }Cash                                                                you t, bo              ari
                                                                   all- fas
                                                                                            c       ore         In many instances, indigent children and their
{ }Charge VISA MC AMEX                 DISC                              k            , a nd m
                                                                   br ea lides            a                     families receive the legal assistance they
                                                                        d            ian                        need on site in the clinic. Other cases may be
Name on Card ______________________________                          an         gic
                                                                           ma                                   referred to volunteer lawyers and supervised
Card# _____________________________________                                                                     law students. Attorneys interested in joining
                                                                                                                the volunteer network should contact Kate
Security Code____________ Exp. Date __________                                                                  Lindsay at (502) 583-5314 or
Zip Code_______________
                                                                                                                                      RELEASE & INDEMNIFICATION
                    CONTRIBUTION FORM
                    Make checks payable to the “Louisville Bar Center.”                                                              This waiver must be signed: In considera-
                    Please bring your contributions to the registration                                                              tion of the acceptance of my entry, I
                    area the day of the run/walk.                                                                                    hereby waive on behalf of my heirs, ex-
                                                                                                                                     ecutors, and assigns, all claims of any
                                                                                                                                     nature arising from my participation in the
                                                                                                                                     Louisville Bar Association’s “Ramble by the
Participant Name:                                 Phone:                                       Email:                                River” and hereby release the Louisville
                                                                                                                                     Bar Association, Louisville Bar Center and
                                                                                                                                     all sponsors, workers, officials and volun-
Name                                    Address                     Email                       Phone              Amount            teers from any claims whatsoever arising
                                                                                                                                     from my participation in this event. I
                                                                                                                                     agree to abide by all the rules for partici-
                                                                                                                                     pation and acknowledge that the Race
                                                                                                                                     Committee may refuse or return my entry
                                                                                                                                     at its discretion. I understand the risks for
                                                                                                                                     such a run and have trained adequately
                                                                                                                                     in preparation. I have noted any relevant
                                                                                                                                     medical conditions on this form.

                                                                                                                                     Relevant medical conditions:


                                                                                                                                     In case of medical emergency contact:


                                                                                                                                     Participant Signature

                                                                                                                                     Parent or Guardian (if under 18)

                                                                                                                                     Printed Name                         Date
                                                                            Total Donations:                          $___________
                                                                            Registration Fee:
                                                                             Level One: $25 (after Aug. 1 -$35)
                                                                             Level Two: $35 (after Aug. 1 -$40)
                                                                            TOTAL ENCLOSED                            $___________

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