Rotary Fest Annual 5K Run/Walk & 1 Mile Fun Run
Sponsored by the Ellisville Rotary Club
October 25, 2008

REGISTRATION FORM

GENERAL INFORMATION AWARDS

Pre-Registration Race Day Registration Trophies go to the 1st Overall

$15.00 for Individuals $20.00 for Individuals Male and Female, 1st Overall $30.00 Family (up to 4) $40.00 Family (up to 4) Masters Male and Female, 1st

  • Pine Belt Pacers will receive a $2.00 discount Overall Grand Masters Male and Female and to the top three finishers in the following age divisions for both male and female.

    • STARTING INFORMATION                                                                    AGE DIVISIONS

    Registration will begin at 7:00 A.M. In front of the Ronald                 Male Female

    E. Whitehead Tech Building, which is located on the right              19 & Under 19 & Under

    At the Howard Tech Park, in Ellisville.                                                    20-29 20-29

    The race will begin at 8:00 A.M.                                                              30-39 30-39

    Parking will be available on location.                                                         40-49 40-49

                                                                                                                         50-59 50-59

                                                                                                                60 & above 60 & 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 the Ellisville Rotary Club, 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)

    Please make checks payable to Ellisville Rotary Club and mail to: Rehab at Work 500 Hill Street Ellisville, MS 39437