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.
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