RUN FROM DRUGS 5k Run and 1 Mile Fun Run
April 28, 2007
Registration Form
A Fund Raiser for  -  Parents for a Drug Free Youth
GENERAL INFORMATION		AWARDS
Pre-registration                Race Day Registration		Trophies will go to the First Overall Male
$15.00 for Individuals               $20.00 for Individuals		and Female, First Overall Grand Masters
$30.00 Family (up to 4)            $40.00 Family (up to 4)		Male and Female , First Overall Masters
		Male and Female and to the top two finishers
*Pinebelt Pacer members receive $5.00 off pre-registration.		in the following age divisions for both male
		and female.
STARTING INFORMATION		AGE DIVISIONS
Registration will begin at 7:00 A.M. in the Parking lot of		Male                                        Female
the Ronald Whitehead  Advanced Technology Center		19 and Under                      19 and Under
in the Howard Technology Park. It is the 1st building		20 - 29                                    20 - 29
once you enter the Tech Park off of the I-59 Entrance		30 - 39                                    30 - 39
		40 - 49                                    40 - 49
		50 - 59                                    50 - 59
*The race will begin at 8:00 A.M.		60 and Above                     60 and above
PLEASE PRINT
Name: ______________________________________________  Phone: ___________________
Address: ____________________________________________  Email: ___________________
City: ____________________  Zip Code: ____________  Male / Female  (Circle One)
Shirt Size: _________________   Age:  ________  Pinebelt Pacers Member:  Y / N
Name: ______________________________________________  Shirt Size: ________________
Age: ________  Male / Female  (Circle One)     Pinebelt Pacers Member: Y /N
Name: ______________________________________________  Shirt Size: ________________
Age: ________  Male / Female  (Circle One)     Pinebelt Pacers Member: Y /N
Name: ______________________________________________  Shirt Size: ________________
Age: ________  Male / Female  (Circle One)     Pinebelt Pacers Member: Y /N
In consideration of accepting this entry, I the undersigned, intending to be legally bound for myself, my heirs, executors and
administrators, waive and release all rights and claims for damages I may have against Parents for a Drug Free Youth  its affiliates, all
sponsors and other organizations associated with this race, their representatives, successors, and assigns, for any and all injuries
suffered by me in said event or arising out of participation in said event. I attest that I am physically fit and have trained for this race.
Further, I hereby grant permission to any and all photographs, video, recordings or any other records of this event for any purpose
whatsoever.
____________________    ____________________    ___________________    ____________________
SIGNATURE (If participant is under 18, please provide signature of parent or guardian)
Mail Registration Form To:                                 5K RUN
C/O Parents for a Drug Free Youth
Post Office Box 2904
Laurel, MS 39442