Earleen Fox Memorial 5K Walk/Run

EARLEEN FOX MEMORIAL 5K WALK/RUN

Date: October 6, 2012

Time: Registration 9:30 am

        Walk begins at 10:30 am

Location: Starts and ends at Diebold Insurance Agency in West Branch, Michigan

Fee: $ 20.00

Contact: Pam Fox Hilts 989-685-2552

RAIN OR SHINE: Cancer doesn't care about the weather. 

This will be a timed event.

Prizes to the top three males and females in walk and run categories.

First Name:________________________

Last Name:________________________

Address:__________________________

_________________________________

Phone Number:_____________________

Birthdate:__________________________

Age on Walk Day:____________________

T-shirt Size:_________________________

Are you a Breast Cancer Survivor?_______

If yes, how many years?_______________

Check one:  Walk_______ Run________

I know that running or walking is a potentially hazardous activity. I should not run or walk unless I am medically able to properly train. I assume all risks associated with participating in this event, including events of weather, traffic and road conditions, all such conditions being known and accepted by me. I waive and release all respresentatives from claims or liablilities of any kind.

X____________________________________

Signature

X____________________________________

Signature of parent or guardian if under 18 years of age

Simply highlight and print.

Mail completed form to:

Pam Hilts

Earleen Fox Scholarship Fund

2853 Campbell Road

Rose City, MI 48654

Checks made out to:

Earleen Fox Scholarship Fund