Please fill out the following information.

Please note your registration cannot be confirmed without receipt of payment, so if you are paying by check, please be sure to mail it to us early.

If registering on-line, please print out your confirmation page and bring it with you when you pick up your packet.

Packet pick-up will be Tuesday, May 29, 2012 from 4:00 p.m. to 8:00 p.m. at Sycamore Park in Anaheim Hills, CA. Additional packet pick-ups will be scheduled. These dates/times will be announced via email blasts and the Taylor’s Wish Facebook page.

Packet shipping available until Saturday, May 19, 2012. The shipping rates are as follows: $10 for the first registrant, $3 for each additional registrant that is shipped to the same address.

T-shirt and bracelet not guaranteed for Late Registration.

Registration will also be available during packet pick-ups.

If running with a team, enter the team name in the "Additional Information/Special Notes" section below.

Personal Information

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone

Email

Age select age... 123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100

Shirt Size * --Select Your Shirt Size-- Adult - Small Adult - Medium Adult - Large Adult - X Large Adult - XX Large Youth - Small Youth - Medium Youth - Large

Team Name

Team Captain Name

Additional Registrants:

Additional Information

Special Notes

How did you hear about us?

Would you like to have your package shipped to you? Select... No Yes Total: $

Are you interested to see TaylorsWish add a 10k Event? Select... No Yes

Payment Method

The registration fee covers the Walk/Run, lunch, an event t-shirt, a TaylorsWish bracelet and one opportunity drawing ticket per person. There will also be a silent auction, entertainment and activities for the kids.

Payment Method * --Select Your Payment Method-- Credit Card Check

Credit Card Type * --Select Card Type-- Visa Master Card American Express *

Credit Card # *

Expiration Date * --Month-- January February March April May June July August September October November December     --Year-- 2012 2013 2014 2015 2016 2017 2018 2019

CCV # *

Billing Information

First Name *

Last Name *

Company

Billing Address *

City *

State *

Zip *

Terms & Conditions

In consideration of the acceptance of my entry, I, my heirs, executors, and administrators, release and forever discharge the Pulmonary Hypertension Association, Taylor’s Wish, The Race Committee, The City of Anaheim Fire Station #10, The City of Anaheim Traffic and Parks Departments, The City of Anaheim and Orange County where this event is held and all sponsors, producers, their agents, representatives, successors and assigns, all of liabilities, claims, action, damages, cost or expenses which I may have against them arising out of, or in any way connected with my participation in this event, including travel to and/or from this event and including all injuries that may be suffered by me before, during, or after the event.

I understand that this waiver includes any claims based on negligence, action or inaction of any of the above parties. Also, none of the above are responsible for any loss of personal property nor any form of aggravation in connection with this event. I recognize the difficulties of this event and attest that I am sufficiently physically fit to compete safely in this event and that I have either been so advised otherwise by a qualified medical person. I also give permission for free use of my name and pictures in any broadcast, telecast or print media accounting of this event.

I understand that the entry fee is non-refundable and non-transferable and the Event(s) will take place rain or shine, at Race Director’s discretion.

I agree to Terms *

Form Verification

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