Monday, September 6, 2010 -- Mount Pleasant, PA / Greenlick Lake
Compete for the Cure Labor Day 5K (iPO Event Id#: 12853)

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Make check payable to and mail to:

"COMPETE FOR THE CURE" c/o Kim Eicher, 620 N. Geary Street, Mount Pleasant, PA 15666

NAME:  _______________________________________________________________________  

PHONE: (_________________) ________________________________

ADDRESS:  ____________________________________________________________________

CITY:  _____________________________________ STATE:  _______ ZIP:  ___________

AGE:  _____     SEX:  ______    BIRTHDATE:  _____/______/___________

E-MAIL ADDRESS:   ____________________________________________________________

5K  RUN  _____   5K  WALK  ______      1-Mile Fun Walk  ______ 

SHIRT SIZE:  CHILD     SM     MED    LG     XLG   XXLG  (PLEASE ADD $2 FOR XXLG)

**In consideration of my entry being accepted in the Compete For The Cure 5K race/run/walk, intending to be legally bound, I waive, for myself, my heirs, executors and assigns any/all rights and claims for damages that I may have or which may hereafter accrue to me against the Compete For The Cure Race, and any/all individuals associated with this race. I understand the difficulty of this event and attest that I am in good physical condition. Permission is also granted to release any photos that include me.

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APPLICANT SIGNATURE

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SIGNATURE OF PARENT (IF UNDER 18)