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:
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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