Registration Form

Runners Name ________________________________________________ Phone Number _________________________________________________ Address _______________________________________________________ Email _________________________________________________________ Are you a runner or walker? Or would you like to donate? Please check one Runner ______ Walker _______ Donation ________

Sarah Schnake is compassionate, humble, loving, artistic and a beautiful girl on the inside and out. At the young age of 17, she has been diagnosed with Pancreatoblastoma. This is a very rare form of cancer. There are less than 200 medically documented cases in the world of this disease. So far, the treatments have been looking positive thanks to Gods healing hand at work, but with a long road ahead of her she still needs our support. Hospital visits, medications, and countless tests are not cheap. Show your support for Sarah and her family as they go through this challenging time by joining in her fight. Register online by visiting the facebook event page 5k for the KnockOut! You can also visit the YMCA or Jimmy Johns on Galena Ave. to pick up a registration form. Race will be held on Saturday, July 28, 2012 at 9:00 am At the Meadows Park off of Washington Ave. Dixon, IL Check-in will be held at Jimmy Johns Friday from 4-6pm or 8 am race day Pre-register by July 14th to guarantee your signature t-shirt.

Shirt Size: S ____ M ____ L ____ XL ____ XXL _____ Fee: $20 You can make checks payable to Sarah Schnake 5k Emergency Contact Person: Name:_______________________________Phone Number:_____________________________
Waiver: I know that running a race is a potentially hazardous activity. I should not enter in this race unless I am physically capable and properly trained. I assume all risks associated with this event. Having read this waiver and accepting all risks that may arise out of being involved in this race, I waive and release the Dixon Park District from all claims or liabilities that may arise from this event. Signature (Parents signature if under 18): __________________________ Date: ____________

For Questions Contact: Parker Ortgiesen (815) 677-3930 or Evan Westart (815) 973-6914 Please mail all entry forms to: Parker Ortgiesen Attn: 5k for KnockOut 1040 Idle Oak Run Dixon, Il 61021