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 $______