5k Walk/Run - Sat. Sept.

22, 2012 Arrowhead Park, Neola, Iowa

Benefiting children and their families suffering from Alternating Hemiplegia of Childhood Registration/Packet pick-up begins at 8:00 am Race begins @ 9:00 am

Thank you so much for your generous support!

To make donations, register, or for additional information visit www.ahckids.org or contact Jackie @ 402-689-6491.

-------------------------------------------------------------------------------Participation Information Name_______________________Phone______________ Address_________________________________________ City_______________________State______Zip________ Age_________ Male___ Female___

T-shirt Size: (Please circle) T-shirt Only ($12) ____ Adult - S, M, L, XL, XXL Child - S, M, L

Pre-Registration (T-shirt included): Late/Same Day Registration:

(T-shirt included while supplies last)

$20.00/person $15.00/child (10 & under) $25.00/person $20.00/child (10 &under)

Pre-Registration is due by September 12, 2012

I hereby release and waive for myself, my heirs, and executors any rights and claims for damages against the sponsors, the race directors and officials, Pottawattamie County, and Arrowhead Park, for any injuries or loss arising out of the 2012 Race for Research.

Date_______________Signature_______________________________________ Parent/Guardian Signature (if under 18)_________________________________

Please make checks payable to: Race for Research Registration forms may be sent to: Farmers and Merchants State Bank, P.O. Box 37, Neola IA 51559