JOAN WILSON 5K ENTRY FORM  2012

NAME______________________________

ADDRESS___________________________

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PHONE_____________________________

E-MAIL_____________________________
AGE (on race day)_________
MALE_ __________ FEMALE___________
T-SHIRT (please circle):
Adult S M L XL
Youth S M L XL

**NEW** Family Rate - Covers all immediate family
members in a household for $35.00 during early
bird registration, $50.00 on race morning. On-line registrations are not available for family discount. Downlaod registration and mail in for family rate.


ENTRY FEE
$13.00  (postmarked by April 11th)
Make checks payable to: Joan Wilson 5K
Send check and completed forms to:
Joan Wilson 5K
c/o Connie Engebretson
503 12th Ave. SW
Le Mars, IA 51031
In consideration of the acceptance of my entry, I for
myself, my executors and assignees, do release and
discharge all race organizers and sponsors from all
claims of damages, actions and causes of actions,
whatsoever, in any manner arising or growing out of my
participation in said athletic event. I hereby attest that
I am physically fit and able to participate in the Joan
Wilson Memorial 5K Run/Walk.
Signature

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Parent/Guardian Signature required if 18 or under:

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