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Thursday, June 7, 2012 -- Connellsville, PA
Highlands Hospital Francis Bud Murphy Memorial 5K Race (iPO Event Id#: 14124)

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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____________________________________________________________________

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__

WAIVER: In signing this entry, I hereby release Highlands Hospital from any claims or responsibility for any injuries suffered by me in this event.

_________________________________________________________________________
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.