 
We have provided several options to make registering as easy as possible for you. 1.) You may REGISTER ONLINE by clicking here. You must register each person separately and a processing fee applies. 2.) You may register in person at:
3.) You may print the registration form below & mail it in along with your check.
Annual 5K & Fun Run Entry Form
Must be received by January 10th, 2010.
Last Name:______________________ First Name:__________________
Telephone:(____)_____-_______ Birth Date:_____/______/________
Event Type: ___5K ___1/2 mile Fun Run
Mailing Address:_______________________________________________
City:_____________________ State:_________ Zip:______________
Email Address:________________________________________________
Emergency Contact:___________________________________________
Relationship:_____________ Phone: (____)_____-________
How did you find out about the race? _____________________________
Which school would you like to support?___________________________
***Very important: Palm Beach County PTA units who get 25 adult participants will be eligible for a Healthy LifeStyles Grant so please mark your choice of schools.***
WAIVER:In consideration of my entry being accepted, I agree to be legally bound and do hereby waive all rights and claims for damages which may hereafter occur against CoachRoudyFightsChildhoodObesity LLC, The Palm Beach County Council PTA/PTSA, AIM, any sponsors of the event or any individuals who are in any way associated with the event from all claims or liabilities of any kind arising out of my participation in this event, even though they may arise out of negligence on the part of the person named herein. I attest and verify that I am physically fit and am fully able to compete in this event. I have read the above release and understand that I am entering this event at my own risk.
Signature of Participant:_____________________________________________
Age ____ Sex ____ T-Shirt Size _____
ENTRY FEES:
$20 Pre-registered Runners • $25 Race Day Registration • $5 Youth 17 & Under
Mail this completed form along with your check to:
PBCC PTA
P.O. Box 881157
Boca Raton, FL 33488
Please note STEP-UP in the Memo of your check
For questions contact:
Robin deLisser
Palm Beach County Council PTA/PTSA
5K Walk Director & Awards Chair
Phone:(561) 283-1950
Email: rdelisser@empowerresources.com |
