Walk begins at 9 a.m. Aug.

27 at Kirksville High School

Team Member/Sponsors Registration
Organization:
Participant Name:
Team Leader Name:
Name

Email

2016 Kirksville
Buddy Pack Walk
Registration

Mailing Address

Phone

Email

Pledge

Signature

Assemble a team of contributors or solicit

sponsorships to raise $180, the price of one
Buddy Pack for the entire 2016-17 school year!

Name
Address

Shirt Size

SINCLAIRBROADCAST

City

State
Phone

Zip

All walkers get a free T-Shirt!

T-Shirt Size: S M L XL
Age:
Gender: M F

Walking Fee:
$12 in advance
$15 day of

I understand that participating in these events is a potentially hazardous activity, which could cause injury or death. By my signature, I certify that I am medically able to participate. I
assume all risks associated with running or walking in this event. I, for myself and anyone entitled to act on my behalf, waive and release the City of Kirksville, The Food Bank, Adair
County YMCA and all employees, board of directors and volunteers, as well as all providers of products or services, from all damages, action and causes of action in any manner arising
or growing out of participation in said races.

Drop off forms & checks at:

Signature (parents signature required if under 18

Chamber of Commerce
ATSU Thompson
Campus Center

The Primary School

KTVO.com
Ray Miller Elementary

Adair County
Family YMCA