Thursday, June 7, 2012 -- Connellsville, PA
Highlands Hospital Francis Bud Murphy Memorial 5K Race
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RACE CONTACT: (e-mail) vmeier@highlandshospital.org
ENTRY FEE . . . $15.00 pre-registration and $17.00 on RACE DAY and $ 5.00 for childrens Lollipop Race.
MAIL TO . . . 401 East Murphy Avenue, Connellsville PA 15425
PAYABLE TO . . . Highlands Hospital
RACE NO.___________ (Offical use only!) NAME____________________________________________________________________WAIVER: In signing this entry, I hereby release Highlands Hospital from any claims or responsibility for any injuries suffered by me in this event.ADDRESS_________________________________________________________________
CITY_________________________________________STATE_______ZIP____________
PHONE (_________________)________________________________
E-MAIL __________________________________________________
AGE ON RACE DAY_________________ BIRTHDATE_______/_______/______________
MALE___ or FEMALE___ RACE SELECTION: 5K RUN___ 5K WALK____
SHIRT SIZE (Please check one): S__ M__ L__ XL__ 2XL__ 3XL__
Youth: S__ M__ L__ XL__
_________________________________________________________________________ SIGNATURE (If under 18, Parent or Guardian MUST sign)
___ I do not plan on attending race day. However, please accept my donation to the Highlands Hospital Center for Autism.
* Entry not valid unless all information herewith is filled out and signed.