Jan Dunn Keller

Heels for Healing Walk

Moseley Elementary School Track
February 12, 2011—9:30 a.m.
1100 Husson Avenue — Palatka, Florida
RAIN OR SHINE!

APPLICATION/ENTRY FORMS:
 Registration begins at 8:30 a.m.—Ceremony starts at 9:30 a.m.
 Use one application per person/team
 Refreshments, prize drawings and awards during event including: Awards for best heel design and style,
most sassy tennis shoes or flip flops, best individual and group fundraiser, and best team spirit
 Service animals allowed
 Strollers are allowed with walking participants only
 T-Shirt guaranteed if registered by January 21, 2011
 Make checks payable to: Lee Conlee House Inc. Memo: In memory of Jan Dunn Keller
 Mail completed entry forms and payment to: Ralph’s House of Flowers, 605 St. Johns Ave., Palatka, FL
32177 (must be received no later than February 7, 2011 - Otherwise, forms and payment will be collected on
day of the event)

**The liability waiver on back of this form must be signed submitted with this application**

Individual/Team Name: ________________________________________________________________________

Name of Parents/Guardians: ____________________________________________________________________

100% cotton T-Shirt (fit not guaranteed):

Individual shirt sizes:  Children Large Adults:  Small  Medium  Large  XL  XXL-add $2

Team shirt sizes: List Number/Sizes of Shirts ______________________________________________________

Address: ____________________________________________________________________________________

Phone Number: _______________________ Email address: ___________________________________________

Check applicable categories:

 ¼ mile high-heeled walk — $20 per adult advance entry fee/$25 per adult day of event fee
 1 mile walk — $10 children 12 & under, $20 adults advance entry fee /$25 per adult day of event fee
 I would like to volunteer to help
 I would like to be a sponsor of the event Participation and sponsorship will honor the
memories of victims and help us to provide the
education, counseling, social services, and
Contact information: Harvey Insurance Agency at 684-4749 development of resources to empower the
or 530-2232, or email daywithoutviolence@gmail.com victims and their children.

All proceeds will be donated to Lee Conlee House

Domestic Violence Center in Putnam County and
Betty Griffin House in St. Augustine
 RELEASE AND WAIVER OF LIABILITY

Putnam County Schools is requiring that the following responsibility clause be

read and signed by the undersigned participant. The completion and return of this
form is a requirement for participation in the Jan Dunn Keller Heels for Heal-
ing Walk event. The undersigned acknowledges that he/she has read and under-
stands the “Key rules of participation and eligibility” which are printed on the
reverse of this form this Release and Waiver.

The undersigned acknowledges that he/she has taken all appropriate steps and
actions to review and assess his/her physical condition and qualification to en-
gage as a participant in the Jan Dunn Keller Heels for Healing Walk event and
that having done so, he/she desires to participate in the Jan Dunn Keller Heels for
Healing Walk event.

RELEASE

The undersigned, in consideration of, and as a condition to, his/her acceptance as

a participant in the Jan Dunn Keller Heels for Healing Walk event, does hereby
release and discharge Putnam County Schools, its Board of Directors, its agents,
affiliates, officers, and employees, and the event organizing members from all
claim, demands or damages which may arise from loss or injury of any nature to
the person or property of the undersigned as a result of participation in said pro-
gram and agrees to indemnify and hold harmless said parties from any and all
loss, damage, or expense incurred as a result of said participation.

I acknowledge that I have carefully read and understand the above state-
ments and agree to the terms and conditions of this release and waiver.

Signature:_______________________________________ Date: _____________

Print Name: _______________________________________________________