September 9, 2017

Proceeds benefit the Miriam Project Adoption Services,

serving children, expectant birth families, and adoptive families around Indiana.

Join Us – Registration is now open – Pre-register and SAVE!!!

Pre-register by August 27, 2017 - $25 (includes long-sleeved t-shirt)

Student (24 & under w/ student ID) - $20 (includes long-sleeved t-shirt)

Race day Registration - $30 (t-shirt not guaranteed)

One Registration Form per Participant (Please Print Clearly)

Name: ______

Address: City:


___

State: Zip: __


Participant Age (Day of Race): ___

Under 14, 15-18, 19-24, 25-29, 30-34, 35-39, 40-44,

45-49, 50-54, 55-59, 60-64, 65-70, over 70.

Phone: email: __

Your Event

a). Men’s 1 Women’s 1

b). 5k Walk 1 5k Run 1 10k Run 1

T-shirt Size (check one): New this year – Long-sleeved t-shirts

XS 1 S 1 M 1 L 1 XL 1 2XL 1 3XL 1


Fee:

$25 Pre-register by August 27, 2017

$20 Student w / ID

$30 Race day Registration (no guarantee of a t-shirt)

Donation: $100 $50 $25

$_ (other amount)

Liability Waiver and Release: I acknowledge that participating in a race can be a potentially hazardous activity. I hereby certify that I am medically able

and properly trained to participate, and I assume all risks associated with this event. If I should suffer injury or illness, I authorize officials of the race to use their

discretion to have me transported to a medical facility and I take full responsibility for this action. In consideration of acceptance, I hereby waive on my behalf, and on behalf of my heirs, estate, executors and assigns, and for all members of my family, all claims of any nature arising from my participation in the Miriam Project 5k walk/run 10k run, and do hereby release all parties associated with this event from any and all claims of liabilities of any kind arising from this event. I agree to abide by all the rules as determined by Madison Park Church of God Inc., and its board, directors and employees, to participate. I hereby grant full permission to any and all of the foregoing to use any photographs, videotapes, motion pictures, recordings or any other record of this event for any purpose. I HAVE READ THE ABOVE LIABILITY

WAIVER AND RELEASE AND UNDERSTAND THAT I AM PARTICIPATING IN THIS EVENT AT MY OWN RISK.

Participant Signature (Required)

Date:


Race Director Use Only

Date:

Parent or Guardian Signature (required for participants under 18 years old)

Saturday, September 9, 2017
15th Annual Race Day!!!
Parking, Registration, Start and Finish at:
Broadway Ministry Center
1400 Broadway, Anderson, IN 46012
Pre-register at a discount & secure your t-shirt
$25 by August 27
Pre-register student
$20 by August 27
Race-day Registration
$30 with no guarantee of t-shirt
On race day (Sept. 9), packet pick-up and
registration will be from: 7:45am – 8:15am
Race begins at 8:30am.
To Register:
·Mail completed registration form and fee to:
Miriam Project Walk/Run
1400 Broadway
Anderson, IN 46012
·Online at miriamproject.org
Course runs through Shadyside Park Trails! / SAVE THE DATE
SEPTEMBER 9, 2017
15th Annual / Saturday, September 9, 2017
15th Annual Race Day!!!
Parking, Registration, Start and Finish at:
Broadway Ministry Center
1400 Broadway, Anderson, IN 46012
Pre-register at a discount & secure your t-shirt
$25 by August 27
Pre-register student
$20 by August 27
Race-day Registration
$30 with no guarantee of t-shirt
On race day (Sept. 9), packet pick-up and
registration will be from: 7:45am – 8:15am
Race begins at 8:30am.
To Register:
·Mail completed registration form and fee to:
Miriam Project Walk/Run
1400 Broadway
Anderson, IN 46012
·Online at miriamproject.org
Course runs through Shadyside Park Trails!