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3rd ANNUAL 5K RACE/WALK
OFFICIAL REGISTRATION FORM
To Raise Money for: American
Diabetes Association
Saturday, September 18, 2010
Palmerton Borough Park, 3rd
and Franklin Ave. in Palmerton, PA
Please submit a separate form for
each participant. Photocopy or print more as needed. Trophies
will be given to fastest overall male and female runners. Medals
will be given to the top 3 finishers in each age category.
Walkers are noncompetitive.
Non-Refundable Entry Fee:
$20.00 before
September 4, 2010 $25.00 after
September 4, 2010
Registration starts at 8a.m. Race
starts at 9a.m. T-shirts to first 100 signed up participants.
Goodie bags to all participants. Bagels, apples/bananas, water, Krank’d
& protein powder drinks available to all participants, while
supplies last!
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Participant’s Information :
(Please fill out entirely)
Name: _____________________________
Address:
___________________________
__________________________________
Circle:
Male Female
Circle:
Run Walk
Phone Number:______________________
E-mail Address:
______________________
Age on September 18th:_______________
T-Shirt Size (Adult): S
M L X L
Age Groups :
(circle the appropriate)
12
& under 13-18 19-29 30-39 40-49
50-59 60 & above
I assume all risks associated with
participating in this event, including, but not limited to:
falls, contact with other participants, the effects of weather,
traffic and the conditions of the road, all such risks being
known and appreciated by me. Having read this waiver and knowing
these facts and in consideration of our accepting my entry, race
officials, volunteers and all sponsors, their representatives,
and successors, are hereby and forever released from any and all
claims or liabilities or any kind arising out of my
participation in this event. I grant permission to all of the
foregoing to use any photographs, motor picture, recording or
any record of this event for any legitimate purpose.
_____________________________________________________
Signature
_____________________________________________________
Signature
(parent/guardian) if under 18
Checks payable to :
The American Diabetes Association (please write in the
note line: Palmerton 5k)
Mail forms and checks to :
C/O Carla Majczan
American Diabetes Association
65 E. Elizabeth Ave., Suite 502
Bethlehem, PA 18018
Questions/Directions :
Call Carla Majczan (610) 248-0447 or Email:
withdrawn88@yahoo.com
Thank you for your support!
*Please also note that your
donations for this 5k are 100% tax deductible. The ADA tax ID
number is 13-1623888*
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