SATURDAY, APRIL 25, 2015
Registration opens at 10:00 A.M Walk/Run to begin at 11:00 A.M Location: YMCA/DuBois Park Cut here and mail SATURDAY, APRIL 25, 2015 Pre-Registration Form Name: Address: City State Zip Sponsor Form On Saturday, April 25, 2015 I will be participating in the 2nd Annual DuBois Walk/Run To Cure Diabetes 2 Mile Walk/8k Run Please support my efforts and sponsor me! Proceeds benefit the American Diabetes Association Name:____________________________ Male or Female Phone: SPONSOR’S NAME T-Shirts Only 75 pre-registered participants will receive a t-shirt on race day. You MUST BE pre-registered by March 25th. To pre-register simply fill out the pre-registration form with a check payable to the American Diabetes Association. MAIL TO: Anita Rajan 508 Treasure Lake Dubois, PA 15801 QUESTIONS: Call Anita at 814-661-2241 PAID Age on race day: Email: T-Shirt Size: Circle One Small We hope you will consider going the extra mile for the walk by asking your friends, family, and co-workers to sponsor our fight to cure Diabetes. This form is optional. You may mail this form along with your pre-registration form, OR bring the form to the pre-registration table on race day. Please collect your money when you are being sponsored. Checks are to be made payable to: American Diabetes Association. These donations are tax deductible. ALL money must be turned in NO LATER THAN April 25th! AMOUNT Med Large Extra Large 2 Mile Pre-Registration: Check One $25 If registered by March 25, 2015 $30 If registered AFTER March 25, 2015 $35 at the door! 8 K Run Pre-Registration: Check One $25 If registered by March 25, 2015 $30 If registered AFTER March 25, 2015 $35 at the door! (WAIVER MUST BE SIGNED) In consideration for being permitted to participate in this event, I, for myself, my heirs, executors, administrators, personal representatives, successors and assigns: I agree to assume all risks arising out of or related to my participation and to release, hold harmless, indemnify, and covenant not to sue DuBois YMCA, DuBois City, Clearfield County and any and all owners of private properties and facilities whose land is used for the event, and any and all volunteers and sponsors as well as their affiliated officers, directors, employees, supporters, agents, successors, heirs and assigns, from all liability to the undersigned, my personal representatives, assigns, heirs, and next of kin for any and all loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the foregoing named parties or otherwise while the undersigned is participating in the event including pre and post event activities. I attest and verify that I understand that participating in the event may be potentially hazardous and that I am both physically fit and have sufficiently trained for the event; I agree to abide by any decision of any event official or medical personnel related to my ability to complete the event; I grant full permission to any and all of the foregoing to use any photographs, videotape, motion pictures, digital recording or any other record of this event that may contain my image for any legitimate purpose, including commercial advertising with any expectation of demand for any payment or other consideration for such use; and I have read the Waiver printed above and agree to it. If participant is under the age of 18: I have read the foregoing and understand the risks involved in participating in this event. I authorize the participation of my son/daughter/ward: ________________________________________________DATE: ______________ Signature of parent/guardian if under age 18 TOTAL AMOUNT Sponsor forms will be available on our Facebook Page! Mail your sponsor form, along with your preregistration form, and checks payable to: American Diabetes Association Anita Rajan 508 Treasure Lake, Du Bois, PA 15801 You may also bring this sponsor form and money collected to the event on April 25, 2015 Thank you for your support!! Statistics about Diabetes! Among U.S. residents ages 65 years and older, 10.9 million, or 26.9 percent, had diabetes in 2010. About 215,000 people younger than 20 years had diabetes—type 1 or type 2—in the United States in 2010. About 1.9 million people ages 20 years or older were newly diagnosed with diabetes in 2010 in the United States. In 2012, the total cost of diagnosed diabetes came to be around $245 billion in the United Thank you to our sponsors: YMCA Nova Nordisk Inc. Aaron's DuBois, PA DuBois Nephrology Associates, P.C. Sanjeev Anand, M.D. Mathew Stainbrook, D.O. The Medicine Shoppe DuBois, PA Penn Highlands Healthcare Perkins Restaurant and Bakery DuBois, PA Penn State Dubois Athletics SANOFI The Med Express DuBois, PA Club Z In-Home Tutoring Culligan Water Brookville, PA Lindsey Water Co. Reynoldsville, PA Timberland Federal Credit Union DuBois, PA Clearfield Bank DuBois Drug and Wellness Asera Care Brookville, PA Dollar $mart DuBois, PA Coldwell Banker The Greater DuBois Chamber of Commerce JCPenney DuBois, PA Staples Zito Media States alone. Diabetes is the leading cause of kidney failure, non-traumatic lower-limb amputations, and new cases of blindness among adults in the United States. Diabetes is the seventh leading cause of death in the United States. There is estimated to be 208,000 Americans under the age of 20 who have been diagnosed with Diabetes. MARK YOUR CALENDAR FOR THE DUBOIS WALK TO CURE DIABETEs! 2 MILE WALK/8K RUN! Registration opens at 10:00 am Race to begin at 11:00 am DuBois YMCA 25 Parkway Drive DuBois, PA Walk To Cure Diabetes! on Facebook
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