CASA Superhero 5K Family Fun Run/Walk

Saturday, July 27th

Onsite registration begins at 6 am/ Race starts at 7:30 am Riverview Park (2000 Harrison Hill) Hannibal

Every Child Needs a Hero, But Abused Children Need Superheroes!

Register by July 6th to be guaranteed a race shirt! Register Online: nemocasa1.eventbrite.com Paper Registration Forms: Douglass Community Services CASA Program 711 Grand Ave, Hannibal, MO Individual Superhero: $20 Superhero Family: $17.50/pp (families of 4-6) League of Superheroes: $15/pp (groups of 10 or more) More Information At: www.Facebook.com/NEMOCASA1 @NEMOCASA

ts! h tig ed, d an urag e cap enco red! r u ire ui o y et o att t req g r fo rher t no t n e u Do Sup b

Douglass Community Services-Court Appointed Special Advocates (CASA) serves children who have been removed from their homes due to neglect or abuse, representing their best interests in court and other settings. Questions? Contact: Samantha Gilland at 573.221.3890 ext. 280 or casa2@douglassonline.org

CASA SUPERHERO 5K/FAMILY FUN RUN

REGISTRATION FORM
(Please Print)

Last name: Email address: Street address: Phone #.: ( ) P.O. box: City: State: If registering as part of a group, indicate League Name: PARTICIPANT INFORMATION Last Name: First Name: Male th T-shirt size: Must register BEFORE July 6 to be guaranteed a race shirt. Small Medium Large X-Large Other: Last Name: First Name: Male th T-shirt size: Must register BEFORE July 6 to be guaranteed a race shirt. Small Medium Large X-Large Other: Last Name: First Name: Male th T-shirt size: Must register BEFORE July 6 to be guaranteed a race shirt. Small Medium Large X-Large Other: Last Name: First Name: Male T-shirt size: Must register BEFORE July 6th to be guaranteed a race shirt. Small Medium Large X-Large Other: WAIVER OF RESPONSIBLITY

CONTACT INFORMATION First: Middle:

ZIP Code:

Female

Age: Adult Age: Adult Age: Adult Age: Adult

Child

Female

Child

Female

Child

Female

Child

Must be completed in order to participate in the Superhero 5K Run and Family Walk. Please read carefully. I (we) and the above-named minor children under my (our) care understand the intent thereof, and I hereby agree and hold harmless the CASA/ Superhero 5K Run, City of Hannibal, Hannibal Parks & Recreation, corporate sponsors, cooperating organizations, event volunteers, and any other parties connected with this event in any way individually or collectively from and against any blame for liability, injury, misadventure, harm, loss, inconvenience or damage thereby suffered as a result of participation in the Superhero 5K Run and Family Walk or any activities associated herewith. I (we) also hereby consent to and permit emergency treatment in the event of injury or illness. I (we) give permission for use of my (our) name/s and photograph/s in connection with this event. I (we) further agree to conduct my (our) activities in a safe and prudent manner. I (we) CERTIFY that all information in this form is true and complete and that I will abide by the rules and instructions of the event, officials, and management. I (we) CERTIFY by my (our) signature(s) below.

Signatures required for all race participants over the age of 18. If under the age of 18, parent/guardian signature required.
Participant/Guardian signature Participant/Guardian signature Participant/Guardian signature Participant/Guardian signature Registration Fees: $20 for Individual Superheroes $17.50 per person for Superhero Families (families of 4-6) $15 per person for Leagues of Superheroes (groups of 10 or more) Make checks payable to: CASA Return completed registration form and payment to: Douglass Community Services- CASA 711 Grand Ave, Hannibal, MO 63401 Contact Samantha Gilland for more information: 573.221.3890 ext, 280 or casa2@douglassonline.org Date Date Date Date