Samantha Elisabeth Porter Memorial Scholarship

Subtitle

Fifth Annual

Running With An Angel 

Samantha Porter 5k Run/Walk


Sunday, March 12, 2017

North Daviess High School

Registration begins at 12:00 p.m.

Kids’ 1 mile fun run starts at 1:30 p.m.

5k (and balloon release) starts at 2:00 p.m.

5k $25

Kids’ 1 Mile Fun Run $15 (for kids 12 and under)


ALL PROCEEDS GO TO THE SAMANTHA ELISABETH PORTER MEMORIAL SCHOLARSHIP


For registration to ensure a t-shirt it must be received by February 27, 2017

(short-sleeved t-shirt included with registration fee)


SHIRT SIZE (CIRCLE ONE):    YS (6/8)   YM (10/12)   YL (14/16)     S    M     L     XL    2XL   3XL


                                First Name _____________________________________ Last Name__________________________________________


                           Street Address _____________________________________________________________________________________


                           City __________________________________________ State _____________________ Zip ______________________


                           Phone (________) _________-_________________ email __________________________________________________


I am registering for (circle one):         5K          Kids Fun Run


                           Additional shirts available (indicate size):                 up to size XL             2XL or 3XL                  Total


                                         Long-Sleeved t-shirt                                       $14 ________         $17 ________          $___________

                                         Hooded Sweatshirt                                         $25 ________         $28 ________         $___________

                                         Registration Fee ($15 Fun Run or $25 5k)                                                                     $___________

                                         Total Amount                                                                                               $__________


WAIVER AND RELEASE


I hereby for myself, and for my minor child (if applicable) and the administrators, heirs, and assigns thereof waive and release any and all rights and claims for damages and personal injuries, including that resulting from negligence, which I or my child may have against Running With An Angel Samantha Porter 5k Run/Walk, its officers, directors, employees, and volunteers; the organizers of the Running With An Angel Samantha Porter 5k Run/Walk; their sponsors, associates, contractors, other entrants and representatives; North Daviess Community Schools, Elnora, Indiana. Daviess County, Indiana, their boards, elected and appointed officials, and their employees, all for property damage or personal injury, including death which may arise or grow out of my or my child’s participation in the Running With An Angel Samantha Porter 5k Run/Walk.  I certify that I and/or my child have prepared for this event.  I agree to follow the rules of this race, obey all traffic laws, avoid littering, and respect the property of others.



__________________________________________      __________________________________________            

SIGNATURE OF PARTICIPANT                                          SIGNATURE OF PARENT/GUARDIAN

                                                                                      IF PARTICIPANT IS UNDER 18


MAKE CHECKS PAYABLE TO: SAMANTHA ELISABETH PORTER MEMORIAL SCHOLARSHIP 


MAIL COMPLETED REGISTRATION FORM TO: Ginger Porter, 11655 North US Highway 231, Odon, IN 47562


For more information call Ginger Porter at (812) 698-0424