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  • Registration Form: All Races Start at 8 A.M. Saturday, July 2, at Dukum Inn, 111 S. Elson, Kirksville

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    Daniel Magruder
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    The document is a registration form for a 5K run and 1.5 mile walk to benefit The Food Bank for Central & Northeast Missouri taking place on July 2nd. Registration is $18 in advance or $20 on the day of the event. Registration forms are due by June 29th and can be turned in at various locations in Kirksville. The event is sponsored by various local businesses and organizations and will include free t-shirts for participants. The registration form collects name, address, age, gender, shirt size, contact information, and a waiver releasing the organizers from liability.

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    2016 Firecracker 5K Registration

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    The document is a registration form for a 5K run and 1.5 mile walk to benefit The Food Bank for Central & Northeast Missouri taking place on July 2nd. Registration is $18 in advance or $20 on the day of the event. Registration forms are due by June 29th and can be turned in at various locations in Kirksville. The event is sponsored by various local businesses and organizations and will include free t-shirts for participants. The registration form collects name, address, age, gender, shirt size, contact information, and a waiver releasing the organizers from liability.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    695 views1 page

    Registration Form: All Races Start at 8 A.M. Saturday, July 2, at Dukum Inn, 111 S. Elson, Kirksville

    Uploaded by

    Daniel Magruder
    The document is a registration form for a 5K run and 1.5 mile walk to benefit The Food Bank for Central & Northeast Missouri taking place on July 2nd. Registration is $18 in advance or $20 on the day of the event. Registration forms are due by June 29th and can be turned in at various locations in Kirksville. The event is sponsored by various local businesses and organizations and will include free t-shirts for participants. The registration form collects name, address, age, gender, shirt size, contact information, and a waiver releasing the organizers from liability.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    PRESENTED BY

    SINCLAIRBROADCAST

    5K run - 1.5 Mile Walk for The Food Bank for Central & Northeast Missouri

    Registration Form
    All races start at 8 a.m. Saturday, July 2, at DuKum Inn, 111 S. Elson, Kirksville
    Brawner Insurance
    Agency, Inc.

    Turn Registration Form and $18 entry fee (checks


    made out to The Food Bank) in by June 29 at
    ATSU Thompson Center, Adair Co. YMCA,
    Chamber of Commerce, Dukum Inn. Or turn in day of
    race on site at 7 a.m. with $20 entry fee.

    Pre-Registration Pick Up 6:30 a.m. - 10 p.m. Friday, July 1 ATSU Thompson Campus Center
    Event sponsored by: Big Boom Sponsors DuKum Inn, Craig & Gina Shorten, Owners and Brawner Insurance Agency, Jeff
    Brawner, Owner: Cherry Bomb Blast Sponsors Grossnickle Insurance, Northeast Regional Medical Center, Adair County Family YMCA: Rocket Round Up Sponsors Kellum Renovations, LLC, Kirksville Farm & Home, Harvey B. Young Jr.,
    ATSU Thompson Campus Center, Century 21 Whitney Agency, Inc.Kraft-Heiniz Kirksville, ATSU Gutensohn Clinic:
    Fountain Friends Sponsors Lori and Jason Haxton, Barrett Law Offices, Hy-Vee Grocery, Lovegreen Ford Mercury,
    Templeton & Swedberg, P.C., Kirksville Dental Group, Northeast Family Health, Lloyd Distributing, Sonnys Collision,
    Walmart-Kirksville, B & H Graphics, Print & Sign, Mary & Vern Playle, Dr. Charles & Sharon Pritchard, Verizon Wireless
    TCC, Northeast Missouri Foot Clinic, Dr. Joe & Sandra Novinger, Smith Moore, Dr. Norman & Deb Clarkson, Lanna &
    James Novinger, Kirksville Women of Today

    CIRCLE ONE: 5K Run 1.5 Mile Walk


    Free T-Shirt. Select Size: S M L XL
    Age:
    Gender: M F

    Name
    Address
    City

    State

    Zip

    Phone

    Email

    I understand that participating in these events is a potentially hazardous activity, which could cause
    injury or death. By my signature, I certify that I am medically able to participate. I assume all risks
    associated with running or walking in this event. I, for myself and anyone entitled to act on my behalf,
    waive and release the The city of Kirksville, The Food Bank, Adair County YMCA and all employees,
    board of directors and volunteers, as well as all providers of products or services, from all damages,
    action and causes of action in any manner arising or growing out of participation in said races.

    Signature (parents signature required if under 18

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