Fundraiser for Susan G.

Komen 3-Day Walk for Breast Cancer

What: 5K run/walk When: November 17, 2012 at 9 a.m. Where: Blue Heron Park (111 Westshore Drive) Cost: $15 per runner Course: Start and end at Blue Heron Park Registration Form: Pick up at Parks and Recreation at 411 Balsam Street Moses Lake, WA 98837 or download at www.facebook/MosesLakeTurkeyTrot2012 or email mlturkeytrot@yahoo.com Mail registration to P.O. Box 1446, Ephrata, WA, 98823 by November 9, 2012. Pick-up: Pick up race number on November 16 between 5:30 7:00 P.M. at Moses Lake Fire Station, 701 E. 3rd Ave., Moses Lake, or pick-up at race from 7:00 8:30 a.m. Awards: 10:15 am at Blue Heron Park. All FINISHERS get t-shirt (registration must be turned in on time to guarantee shirt); medals for 1 , 2 , and 3 place finishers of each division Divisions: Male and females; 6 & under, 7-10, 11-14, 15-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70+ LATE REGISTRATION: If you submit your registration form after the deadline of November 9 t-shirts are not guaranteed. There will also be day-of registration, but no shirt given.
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Moses Lake Turkey Trot Entry Form NOV.17, 2012

Name______________________________ Phone____________________ Address___________________________ City_________________ ST_____ Zip_______ E-mail Address_____________________________ T-Shirt (circle one) YS YM YL AS AM AL AXL AXXL

Division Male____ Female____ Age Group 6 &under___ 7-10___ 11-14___ 15-19___ 20-29____ 30-39___ 40-49___ 50-59___ 60-69___ 70+____
Make Checks Payable to: Susan G. Komen 3-Day Drop off or mail to: P.O. Box 1446, Ephrata, WA 98823 Website: www.facebook.com/MosesLakeTurkeyTrot2012 Contacts: Karrie Grant 509-855-3261 Kelsie Grant 509-855-1692 Brook-Lyn Fankhauser 509-304-4585 Terrah Bicondova 509-398-1232 mlturkeytrot@yahoo.com
Waiver: I know that running a road race is potentially hazardous activity. I will not enter and participate unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to any aspect of my participation in this event, including the right of any official to deny or suspend my participation for any reason whatsoever. I assume all risks associated with running in this event, including but no limited to: falls, contact with other participants, the effects of the weather, including high heat and/or humidity, traffic and the conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the Moses Lake Turkey Trot, race officials, all event sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event.

Signature or Parent Signature___________________________________

Date:______________