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iCureMelanoma 5K Registration
MAY,2 2015
CONTACT INFORMATION
First Name
Last Name
Address
City, State, Zip
Email
Phone
Which Wave Will
You Be Running in?
Competitive
Adult/Youth/
(< 9 min. pace)
Senior
Would you like to purchase a RAFFLE TICKET?
$10 Each | Bundle: 20 for $100 ($100 savings!)
Includes over $25,000 in donations from sponsors and
vendors.
# of
# of
TOTAL
Individual
Bundle
TICKETS
Tickets
Packages
Birthdate
Kids
Fun Run
YOUTH
ADULT
Small
Small
WOMEN’S V-NECK Small
Estimate # of Team Members
Team Captain Name
T-SHIRT SIZE:
YOUTH
ADULT
Small
Small
REGISTRATION INCLUDES
FREE SKIN CANCER SCREENING
Disposable Bib-Chip Timing
Participant T-Shirt
Sport Sack Goody Bag
Vendor Donations, Sunscreen Samples
Age Bracket Custom Medals & Prizes for Top Placers
Finisher Medals
Access to Community Vendor Fair …Raffles & more!
SCHEDULE OF EVENTS
Friday, May 1st, 2015: (10:00 am - 6:00 pm)
FREE SKIN CANCER SCREENING (registered participants)
Registration- Packet Pick Up
@ Full Spectrum Dermatology
333 W. Bastanchury Road, Ste. 110, Fullerton, CA 92835
Saturday, May 2nd, 2015:
@ Laguna Road Elementary School
300 Laguna Road, Fullerton, CA 92835
 6:00 AM
Registration Opens
 7:00 AM
Competitive Wave Begins
 8:00 AM
Open 5k Run/Walk Begins
 8:15 AM
Awards & Prizes for Competitive Wave
 9:15 AM
Awards & Prizes for Open 5k
 9:30 AM
Kids Fun Run!-Sponsored by Mother’s Market Brea
CONTACT INFORMATION
Kelly Clauss (714) 292-6146
Email: [email protected]
www.iCureMelanoma5K.org
Yes
No
Medium
Medium
Medium
Large
Large
Large
XL
XL
XXL
XXL
Large
Large
XL
XXL
(circle one)
Medium
Medium
REGISTRATION FEES:
Team T-Shirt Color ( for teams of 15+)



Receive a Free
Skin Screening?
# of T-shirts
Please fill out the information below for your team:








Age (on race day)
Would you like to purchase a “Keep Calm and
Wear Sunscreen” T-shirt? (T-shirts are Red)
$20 Each | $30 for 2 ($10 savings!)
TEAMS
Team Name
Female/Male
COMPETITIVE*/ADULT
YOUTH (17 & under)
SENIOR (65+)
KIDS FUN RUN
Early Reg.
(Before 2/1)
$40.00
$35.00
$30.00
$15.00
Regular Reg. Late Reg.
(After 2/1) (On 5/1)
$45.00
$50.00
$40.00
$45.00
$35.00
$40.00
$20.00
$25.00
*Competitive must be at less than 9 min. pace or better
MAIL-IN REGISTRATION:
Please make checks payable to: MelanomaCure.org
Registration fees are non-refundable and non-transferable.
iCureMelanoma 5K / ATTN: Kelly Clauss
333 West Bastanchury Road • Suite 110, Fullerton, CA 92835
ONLINE REGISTRATION: www.iCureMelanoma5K.org
WAIVER (One Entry Form per Registrant)
I acknowledge that I voluntarily apply to run in the iCureMelanoma 5K, and
that there are risks inherent in the race which may result in serious injury and
property loss or death. I assume the risk of participating. In consideration of
this entry acceptance in the iCureMelanoma 5K, I hereby for myself, heirs,
executors and administrators waive any and all rights and claims for
damages against Full Spectrum Dermatology, MelanomaCure.org, the City of
Fullerton, and all participating sponsors and their officers, agents, & any
individual or organization associated with iCureMelanoma 5k for any and all
losses, injuries or death sustained by me in this event. I hereby certify that I am
in good physical condition and am able to safely compete in this event. I
consent to receive medical treatment should I sustain injury during the event.
Additionally, I permit the use of my name and pictures in broadcasts,
telecasts, newspapers, brochures, etc. as a participating athlete. I certify all
information provided by me in this form to be true and complete. I have read
the entry information provided for the event and certify my compliance with
my signature below:
Signature (parent/guardian’s signature if runner is under 18
___________________________________________________________
Date
____________