Registration: 9Am 5K Run/Walk: 10Am Fun Run: Following 5K

Hosted by Student IMPACT October 3, 2009

Registration: 9am 5K Run/Walk: 10am Fun Run: following 5K

The students of IMPACT are presenting a 5K Run/Walk for Norwalk and surrounding communities. The event will be held at the Veteran’s Memorial Lake Park (Norwalk reservoir, north entrance) along the cross-country course. Awards will be presented to top male/female times and first and second place in each of the following age groups: 13 & under; 14-19; 20-24; 25-29; 30-39; 40-49; 50-59; 60+. The first 100 registrants will receive a T-shirt (extras may be available the day of the race). A 1-mile Fun Run for kids ages 6-12 will follow the 5K run again this year. There will be a 30 person limit, and each child will receive a medal.

Costs

$15 - before 10/2 $18 – 10/3 Day of 5K $5- Fun Run

Make checks payable to: Successful Relationships

Return Registration Form to: Successful Relationships

124C Cleveland Ave.

Norwalk,OH 44857

For further information contact: Nathan Phillips

cell: 419-706-9225

email:

Name_______________________________________________________________ 5k ______

Fun Run ______

(please check one)

Age__ Age_________ Phone _________________________________________

Address_____________________________________________________________

City ______________________________________ State ______________ Zip ________________

Email _____________________________________

Shirt Size (Please Circle) S M L XL XXL

I agree that I will not hold Student IMPACT or the City of Norwalk liable for any injuries incurred

during the 5K IMPACT Run. I presume all responsibility as a result of being permitted to participate in this event.

Signature___________________________________________ Date:____________

________________________________________________________________________________________________

Office Use Only

Date ________________ Receipt # __________________ Pay Type _________________