MARTY’S MUSTANG SCAMPER 5K RUN/WALK All Proceeds benefit the LC High School Baseball Program Saturday, April 11, 2015 – Rain or Shine 8:00 AM Van Lieshout Park Registration Form One registration form is required per participant. Additional Registration Forms available on www.littlechutediamondclub.com I plan to: _____Run ____Walk Last Name ______________________________First Name______________________ Address________________________________________________________________ City____________________________________State_____________Zip___________ Phone__________________________________Email___________________________ Date of Birth____/____/________Gender_____________________________________ T-Shirts will be provided to all pre-registered runners. Those registering on race day will receive shirts on a firstcome first-served basis. Available sizes are: YOUTH: S M L ADULT: S M L XL XXL (Circle One) Payment ____Adult Pre-registration until 4/4/14 $20.00 ____Adult Pre-registration after 4/4/14 $25.00 ____Youth 17 & Under $15.00 Sub-Total My Personal Donation to support High School Baseball Total ________ ________ ________ ___Enclosed is my check for $_________ payable to: Little Chute Diamond Club and send to: Little Chute Diamond Club, 3345 Streamview Lane Appleton, WI 54913 or Drop Off at Little Chute Park & Rec Dept – 1940 Buchanan Street, Little Chute Waiver: I hereby declare, assert and affirm that my participation in Marty’s Mustang Scamper 5K Run/Walk is done having knowingly and voluntarily assumed ALL RISKS involved in this Special Event. Print Name___________________________________ Date _____________________________ Signature______________________________________ Parent/Legal Guardian must sign if participant is under the age of 18 ***For Questions email Head Coach Dean Birling @ [email protected] or call 920-740-6121***
© Copyright 2024