Heart Choices is a Christ-centered facility which provides counseling and support services to women and men experiencing

unintended pregnancies, helping them to come to a better understanding of their options and the consequences of their choices. Your participation in this fundraising race enables us to offer HOPE to these individuals by providing the following services: • Pregnancy Tests • Options Counseling • Pregnancy and Parenting Education • Abstinence Education • Adoption Information • Maternity and Baby Items • Referrals to Outside Agencies • Post Abortion Counseling and Support •“Seven Myths of Sexuality” Presentations to area Junior and Senior High schools • All services are free and confidential THANK YOU FOR YOUR SUPPORT!

www.heartchoicesbeloit.com

REGISTER ONLINE AT PLEASE REGISTER
6th & Independence • P.O. Box 96 Beloit, Kansas 67420 785-738-3433 • heartbeat@nckcn.com.

by September 2, 2011 to receive a free t-shirt

Chautauqua Park Beloit, Kansas

You can now

Return service requested

Non-profit Org.

U.S. POSTAGE

Permit No. 96

PAID

PARTICIPANT
Please check one

n CHILD (12 AND UNDER)

n TEEN (13-18)

n ADULT

_______________________________________________________________________________________________ NAME ADDRESS

Heart Choices is a 501(c)3 Non-Profit organization. All contributions are tax deductible.

_______________________________________________________________________________________________ CITY / STATE / ZIP _______________________________________________________________________________________________ TEAM NAME TEAM CAPTAIN

ARE YOU “ONLINE”? DO YOU EMAIL, FACEBOOK, OR TWITTER? If so, go to our website www.heartchoicesbeloit.com

to register as a participant. Simply enter your basic information, then you have the option to upload your information to your own personal Walk-Run 4 Life website.You can even upload your own picture and a personalized message of why you choose to support Heart Choices. You may then email or share the link to your website with your entire address book, giving all your friends and family the option to sponsor you with an online donation! The possibilities are limitless! It’s easy and fun – you don’t even have to go door to door! If you have questions, contact us at 785-738-3433 and we’ll help you through it.

“Run with perseverance the race...”

NOTE: If you have registered online and have entered sponsors and their pledges online, DO NOT ENTER those sponsors and their pledges on this form.
SPONSORS

Address Email Donation Amt. Pledge Amt. (*Bill ____________________________________________________Me) $ | | | n ____________ | $ cash n check ____________________________________________________ $ | | | n ____________ | $ cash n check ____________________________________________________ $ | | | n ____________ | $ cash n check ____________________________________________________ $ | | | n ____________ | $ cash n check ____________________________________________________ $ | | | n ____________ | $ cash n check ____________________________________________________ $ | | | n ____________ | $ cash n check ____________________________________________________ $ | | | n ____________ | $ cash n check ____________________________________________________ $ | | | n ____________ | $ cash n check ____________________________________________________ $ | | | n ____________ | $ cash n check ____________________________________________________ $ | | | n ____________ | $ cash n check ____________________________________________________ $ | | | n ____________ | $ cash n check ____________________________________________________ $ | | | n ____________ | $ cash n check ____________________________________________________ Donor Name

HEBREWS 12:1

*IF DONOR WISHES TO BE BILLED, PLEASE PROVIDE COMPLETE ADDRESS WITH ZIP CODE. MAKE CHECKS PAYABLE TO HEART CHOICES. All donations are tax deductible.

Amount turned in with this form. $____________ Amount to be billed. $____________

involved with its cross country season. It is permissible for them to participate IF they have finished their regular season before Sept. 18th AND they are not going on to regionals or state competition. Track athletes will NOT be affected since this is a fall activity.

Q. Where will the events take place?

Registration will begin at 2:15 PM in front of the white building at Chautauqua Park, South Hersey St, Beloit. The Kid’s races will be run inside the park. The 5K run will go south on Hwy 14 with a mid-way turn around, ending at the park. The walk route will travel north on Hersey Street to Main street, stopping at the Courthouse for prayer, then continuing west to Mill Street, turning South to return to the park. The 16 mile bike race route will go south on Hwy 14 to Tipton blacktop, turn on 250 Rd/W. Main Street and complete a loop back to Chautauqua Park. Q. Will there be prizes? Medals will be awarded to the top three competitors in the individual age categories for the 5K, Kid’s Run, and the Bike Race. There will be prizes awarded to the TEAM who collects the most money and pledges (each team member will receive a gift). Prizes to the top INDIVIDUAL collectors will be: • Child (12 and under) - New Child’s bicycle
• Teen (13-18) - $50 Visa Gift Card • Adult (19 and over) - $50 Visa Gift Card

Q. How can I participate? You may participate individually, or as a part of a team (maximum team size - 10 people). You also have the option of paying only the $20 registration fee, OR collecting pledges for Heart Choices. Anyone who registers by September 2, 2011 and pays the $20 registration fee or collects pledges amounting to $20 or more will receive a FREE T-SHIRT. It is not necessary to walk, run, or bike to register.

2:15 pm - Registration 2:30 pm - 16 Mile Bike Race Start 3:00 pm - ½ Mile Kid’s Run Start 3:30 pm - 1 Mile Walk Start 3:35 pm - 5K Run Start • All Times Approximate - May be adjusted slightly • At the end of all races, a meal will be provided for all participants. • During the meal, door prizes will be drawn. The awards ceremony will begin once all times and places are determined.

Each registered participant will be entered into a drawing for door prizes donated by area businesses. Q. Can high school athletes compete? It is NOT permissible under the KSHSAA rules for a cross country athlete to participate in the 5K run that is a fundraiser for Heart Choices on Sept. 18th if they are part of a school team that is currently

Please cut out and return this form

Please check the category in which you will participate
n PLEASE PRINT CLEARLY _________________________________________________________________ NAME _________________________________________________________________ ADDRESS _________________________________________________________________ CITY / STATE / ZIP _________________________________________________________________ HOME PHONE / CELL PHONE _________________________________________________________________ E-MAIL _________________________________________________________________ CHURCH/ORGANIZATION _____________________ AGE n MALE n FEMALE n

5K RUN

n

1 Mile WALK

n

.5 Mile KIDS RUN

16 Mile BIKE RACE (14 and older) ALL BIKE RACERS ARE REQUIRED TO WEAR HELMETS. FOR YOUR SAFETY, PLEASE NO HEADPHONES.

Fill out if participating on a team.
_________________________________________________________________ TEAM CAPTAIN _________________________________________________________________ TEAM NAME

T-SHIRT SIZE YOUTH: n SM n MED n LARGE n XL ADULT: n SM n MED n LARGE n XL n XXL n Other ______

I hereby waive and release any and all rights and claims against the event organizers, sponsors, and Heart Choices, for any injuries or health problems suffered by me in connection with this event. I further certify that I am in good enough physical condition to participate in this event.
n

Pre-register by September 2, 2011 to guarantee a free t-shirt. Mail or drop off registration and $20 entry fee to Heart Choices. You can also bring the completed form with you the day of the event or register on the day of the event. For more information, call 785-738-3433 or e-mail questions to heartbeat@nckcn.com. Don’t forget, you can register online at www.heartchoicesbeloit.com and set up your own personal webpage for collecting pledges and donations.

Parent or guardian signature required if under 18.
_________________________________________________________________ SIGNATURE DATE _________________________________________________________________ PARENT OR GUARDIAN DATE