Participant Registration

Choose from one of the following options to continue registering:

I AM A NEW
PARTICIPANT

Participant First Name:*

Participant Last Name:*

Participant Email:*

Confirm Email:*

By registering as a participant and providing your email address, you are agreeing to receive important participant event updates via email.

User Name:*

A user name and password must be entered in order to be able to access and update your personal fundraising page.
Enter a unique user name for each participant of the event. No spaces allowed.
(i.e. first and last name: janedoe or first initial and last name jdoe)

Password:*

Minimum 6 characters. At least one letter and one number.
Only enter letters, numbers, periods, hyphens or exclamation marks.

Confirm Password:*

I would like to set a goal of:*

Help further support the clinic by setting a fund raising goal and asking friends and family to support you in the race! The goal that you choose now can be edited on your registration profile at any time.

In addition to registering, I would like to make a donation in the amount of:

$.00

Date of Birth:*

(mm/dd/yyyy)

What is your mailing address? Please include street name, city, state, zip code, and PO Box / Apartment number if applicable.:*

Release and Wavier In consideration of this entry being accepted, I hereby for myself, heirs, executors, and administrators, waive and release any claim I may have against the HAVEN Free Clinic, its officers and directors, the organizing committee, the sponsoring organizations, the city of New Haven or their representatives, successors, or assignees for any injury that may be suffered by me at or in this event.

Release:*

I have carefully read this Waiver and fully understand its contents. I am aware that by accepting this Waiver, I am waiving legal rights and knowing this, I accept it of my own free will.

What is your T-Shirt Size? *Note T-Shirts must be picked up locally at Campus Customs New Haven*:*

Small
Medium
Large
X-Large
XX-Large

Date of Birth:*

(mm/dd/yyyy)

What is your mailing address? Please include street name, city, state, zip code, and PO Box / Apartment number if applicable.:*

Release and Wavier In consideration of this entry being accepted, I hereby for myself, heirs, executors, and administrators, waive and release any claim I may have against the HAVEN Free Clinic, its officers and directors, the organizing committee, the sponsoring organizations, the city of New Haven or their representatives, successors, or assignees for any injury that may be suffered by me at or in this event.

Release:*

I have carefully read this Waiver and fully understand its contents. I am aware that by accepting this Waiver, I am waiving legal rights and knowing this, I accept it of my own free will.

What is your T-Shirt Size? *Note T-Shirts must be picked up locally at Campus Customs New Haven*:*

Small
Medium
Large
X-Large
XX-Large

Date of Birth:*

(mm/dd/yyyy)

What is your mailing address? Please include street name, city, state, zip code, and PO Box / Apartment number if applicable.:*

Release and Wavier In consideration of this entry being accepted, I hereby for myself, heirs, executors, and administrators, waive and release any claim I may have against the HAVEN Free Clinic, its officers and directors, the organizing committee, the sponsoring organizations, the city of New Haven or their representatives, successors, or assignees for any injury that may be suffered by me at or in this event.

Release:*

I have carefully read this Waiver and fully understand its contents. I am aware that by accepting this Waiver, I am waiving legal rights and knowing this, I accept it of my own free will.

Date of Birth:*

(mm/dd/yyyy)

Release and Wavier In consideration of this entry being accepted, I hereby for myself, heirs, executors, and administrators, waive and release any claim I may have against the HAVEN Free Clinic, its officers and directors, the organizing committee, the sponsoring organizations, the city of New Haven or their representatives, successors, or assignees for any injury that may be suffered by me at or in this event.

Release:*

I have carefully read this Waiver and fully understand its contents. I am aware that by accepting this Waiver, I am waiving legal rights and knowing this, I accept it of my own free will.

Date of Birth:*

(mm/dd/yyyy)

Release and Wavier In consideration of this entry being accepted, I hereby for myself, heirs, executors, and administrators, waive and release any claim I may have against the HAVEN Free Clinic, its officers and directors, the organizing committee, the sponsoring organizations, the city of New Haven or their representatives, successors, or assignees for any injury that may be suffered by me at or in this event.

Release:*

I have carefully read this Waiver and fully understand its contents. I am aware that by accepting this Waiver, I am waiving legal rights and knowing this, I accept it of my own free will.