Runner's Name__________________________ Address________________________________
City____________________________________ State________ Zip______________ Sex____
Runner's Cellphone__________________________ Home Phone__________________________
Work Phone___________________________ Email Address____________________________
Emergency Contact_____________________ @ Emergency Phone # ____________________
Please use someone NOT at the event as your Emergency Contact.
Runner's Birthdate__________ Runner's Gender __________ Group ____________________]
Circle event: Tot Trot One Mile Fun Run 5K Run
| 2011 Autumn Run Registration and Options Workbox |
| ITEM |
DETAILS |
QTY/PRICE |
SUBTOTALS |
| 5K Runner Fee |
$25 |
Qty One(1) |
$ |
| Tot Trot |
FREE |
Qty One(1) |
$ 0 |
| One Mile Fun Run |
$25 |
Qty One(1) |
$ |
| Earlybird> |
Postmark by 10/26/11 |
and subtract $5 |
-$ |
| Group Discount> |
Postmark by 10/26/11 |
subtract add'l $2 |
-$ |
|
All group members' (10 or more) forms must be submitted together with payment(s) for Group Discount.
|
| Additional Donation |
Gratefully accepted! |
- - -> |
$ |
| Runner T-Shirt |
Circle Size S M L XL XXL
Kids S M L |
Qty One(1) |
Included |
|
T-shirts guaranteed to paid Earlybird runners only.
|
| Extra Event T's |
Size ____ Size____ Size ____ Size____ |
#____@ $18.00 ea |
$ |
| Earlybird extra T's> |
Postmark by 10/26/11 |
and subtract $3 ea |
-$ |
GRAND TOTAL INCLUDED (checks and money orders only)
Payable to The Autumn Run |
$ |
By affixing my signature I attest that I have read and agree to the
Autumn Run Liability Waiver
and I further agree to sign waivers as necessary at registration, including a copy of the Autumn Run Liability Waiver.
Signature____________________ Guardian sign here under 18 years_____________________
Registration/check-in opens at 12:30 pm Nov 6, 2011
Event held rain or shine! NO REFUNDS!
