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Heather’s Healing Run & Walk

5K & 1 Mile www.heathershealing.blogspot.com Entry Form

A family friendly event & fundraiser to Name: _____________________________________________


support Heather in her cure from cancer. Address: ___________________________________________
City, State, Postal Code: ______________________________
September 4th, 2010 Telephone: _________________________________________
2:00pm Email: _____________________________________________
Columbiana County Fairgrounds Relationship to Heather: _______________________________
225 Lee Ave. Lisbon, Ohio
Would you like to order a T SHIRT for $12? □ Yes □ No
Further information and online registration:
www.heathershealing.blogspot.com How Many? ______ Size(s) ________
or detach and
Mail Registration To: ** ORDERS MUST BE RECEIVED BY AUGUST 16TH **
PO Box 3, Leetonia, OH, 44431 I hereby waiver all claims for injury, death, illness, property damage, and/or loss, including claims for negligence,
(Checks payable to Heather Sorg) both for myself and my heirs, which I may as a consequence of my involvement in the run/walk, the race director,
and members of her committee and all other people associated with Heather’s Healing Run & Walk, the Town of
Lisbon, and the Columbiana County Fairgrounds. I acknowledge that running/walking include inherent risks and in
Late Registration @ the Fairgrounds on Sept. 4th from signing this form, it is my intention to accept those risks and consequences thereof. I acknowledge that I have read
1:00-1:30pm this release in its entirety. I understand and agree to be bound by its terms.

Donations will be accepted on Event Day.


Signature ____________________________________ Date _____________________
This event will not be timed & there will be no age category
Parent/Guardian_______________________________
prizes.
All registered runners and walkers are eligible for draw prizes.
You must be present to win. DONATION $ _____ + TSHIRT $ _____ = TOTAL ENCLOSED $______

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