Erin Shanley Memorial 5K Race

All Proceeds Benefit St. Jude Childrens Research Hospital August 12th, 2012 @ 9:00 AM Stissing Pond (Lions Club Pavilion) Pine Plains, NY
5K/1 Mile Race start at 9:00 A.M Registration Due: August 8th, 2010 Race Day Registration 8:15-8:45 AM Registration (circle one): $10 for 5K
$5 for 1 mile race Additional $10 for an Erin Shanley Memorial T-Shirt (all t-shirt orders MUST be in by July 30th)
Top Male/Female Finishers for each Race Receive Awards! Directions from Route 82/199 Intersection (Pine Plains): Head west on E. Church St. towards South Main St. Take the second left onto Poplar Ave. Take the first right onto Stissing Ave. Continue towards the Lions Club Pavilion parking lot. Make Checks Payable To: St. Jude Childrens Research Hospital Mail To: Tim Reynolds Attn: 5K Entry 11 Rowe Road Red Hook, NY 12571

Application Must Be Signed

I agree by signing that I am in good health and I do hereby for myself, my heirs, executors, administrators and assignees, release and forever discharge the sponsors and all those involved and manning this event, from all claims of any kind arising as a result of my participation in this event. Signature:__________________________________ Date: _____________ Email Address: _____________________________ If under 18 Parent or Guardian must co sign:_____________________ Date:__________

Please contact Tim Reynolds with questions at (845) 214-7801 or t.reynolds1026@gmail.com