REGISTRATION FORM - RELAY 5K Race

    


Name: __________________________________________

 

Age (at race date)/gender: _____________________________

 

Address: ________________________________________

 

City, State, Zip: ___________________________________

 

Phone (      ) - _______ - ________

 

Emergency Contact (name and phone number): ____________________________________

 

Prizes awarded to the top 3 overall finishers

 

Entry Fee: Please make your check payable to the American Cancer Society, 1948 East Third Street Williamsport, PA 17701.  Return form and fee to: Kayla James at PO Box 67, Danville, PA 17821 or kaylah0228@yahoo.com.

• Registration before May 10: $20
  
  

• Registration on or after May 10: $25
  
  
• Children 12 years old and younger: free
  
   
  
  Disclaimer: For and in consideration of permission to participate in this race, I for myself, my heirs, executors and administrators, do hereby release and discharge the sponsors, contributors, officials, employees and all of the members and officers of the American Cancer Society, Relay For Life, the borough of Riverside, PA, from all claims and damages arising from my participation in this race. I attest and verify that I am physically fit and have sufficiently trained for this event.
  
   
  
   
  
  Signature/Date: ________________________________________________________
  
  (Parent Signature if under 18)