Dellwood Park - 8:30am www.facebook.

com/MPCancerCrusade
Name: ________________________________________ Age (as of 10/20/12): _________ DOB: _____/______/______ Sex: Male Female Email: _____________________________________________________________________ Address: ______________________________________________________________________________________________ City: _____________________________ State: _________ Zip: ___________ Phone: _____________________________ Emergency Contact Name/Phone: ____________________________________________________________________ 5K REGISTRATION FEES $25 Early Registration $30 Late Registration (after 10-15-12) SHIRT SIZE Small Medium 10K REGISTRATION FEES $25 Early Registration $30 Late Registration (after 10-15-12) Large XL XXL

Note: Deadline for receipt of entry forms by mail or email is October 15th. After the deadline, registration is available only at Dellwood Park on the event day. All registered participants will pick up their packet and number between 7:30 am-8:15 am on October 20th. All fees are non-refundable.

5K/10K Registration Fee: Additional tax-deductable donation TOTAL ENCLOSED:

$______________ $______________ $______________

Make checks Payable and Mail Entries to: Mt. Pleasant Cancer Crusade c/o Titus Regional Foundation P.O. Box 289 Mt. Pleasant, TX 75455
CREDIT CARD PAYMENTS: Contact Lynda Stringer, Titus Medical Foundation Coordinator, at lynda.stringer@titusregional.com or call 903.577.6366.

Waiver Statement: In consideration of acceptance of this race entry, I, myself, my heirs, executors, administrators and assigns, forever release and discharge any and all rights, demands, claims for damages and causes of suit or action known or unknown that I may have against the Mt. Pleasant Cancer Crusade and any and all participating race presenters, sponsors, directors, officers, employees and agents of such parties, for any and all injuries in any manner arising from my participation in said race. I attest to and verify that I have full knowledge of the risks involved in the race, I assume those risks and I will assume and pay my own medical and emergency expenses in the event of an accident, illness or other incapacity, regardless of whether I have authorized such expenses. I am physically fit and sufficiently trained to participate in this race. I understand that no bikes, roller blades, or pets are permitted in the 5K or 10K races.

____________________________________________________________________ Signature (participant or Parent/Guardian if under 18)

_____________________________________________ Date

100% of proceeds benefiting Patty & Bo Pilgrim Cancer Center

Thanks for your Support!