5K , 1 MILE RUN, & 100 YD DASH

SATURDAY, SEPTEMBER 29, 2012, FLORA, ILLINOIS

(WALKERS WELCOME!)
Sponsored by: Xenia Manufacturing, Inc. Lisa Erbacher, Country Financial Representative, Docs Gym, Clay County Chiropractic, Powless Law Office, Melanie Pearce, Attorney at Law, The Gym, and Crystal Ballard for Circuit Clerk

Special Thanks to: the FHS Football Program, ESDA, Coalition Against Drug Abuse (CADA), and Hometown IGA, 2012 ENTRY FORM NAME____________________________________________________________
_________________________________________________________ _________________________
ADDRESS CITY STATE ZIP EMAIL ADDRESS AGE ON DATE OF RUN

Waiver: By signing below, I do hereby release and discharge from liability the Flora Academic Foundation and the City of Flora, organizers, event sponsors, supervisors of the FAF Appleknocker Run and their representatives, successors and assigns for any and all causes of action, claims, and injuries suffered by me in this event, however incurred. I attest and verify that I have sufficiently trained for the completion of this event. As a parent or guardian of the applicant (if applicant under the age of 18), I hereby consent to the participation of the applicant in the race under the above mentioned conditions. Signature________________________________________________________________________________________________ Date_________________ Parent/Guardian________________________________________________________________________________________ Date_________________
PREREGISTRATION/REGISTRATION FEE: 1 Mile $10 & 5K $15 for 5K if entry forms received before Sept. 20 Same Day Registration Available 1 Mile $12 & 5K $20 if entry forms received on or by Sept. 20 100 yard dash FREE for children 8 years old and under (No shirt provided)

*All participants in the 100 yard dash will receive a ribbon

Final registration begins in front of FHS at 8:00 AM the day of the race and closes at 8:30 AM 100 yard dash begins at 8:30 AM 5K & 1 Mile runs begin at 8:45 AM in front of Flora High School

Those pre-registered by Sept. 20th for 5K and 1 Mile are assured of receiving a Moisture Management T-shirt.

Extra shirts will be ordered but will be available only while supplies last to those registered on or after Sept. 20th.
CATEGORY: AGE CATEGORY (CIRCLE ONE): _____ 5K RUN 18 & under; 1924; 2534; 3544; 4554; 55 & older _____ 1 MILE RUN 8 & under; 911; 1215; 1619; 20 & older _____ 8 AND UNDER DASH -- ALL PART PLEASE CIRCLE YOUR T-SHIRT SIZE. IF NOT MARKED, YOU WILL RECEIVE A MEDIUM. YOUTH SIZE: SMALL MEDIUM LARGE ADULT SIZE: SMALL MEDIUM LARGE X-LARGE *XXL *ADD $2

*NOTE: Historically, shirts have run on the large side-- consider being conservative when you choose!
Computerized Timing Services by Larry B. Williams, A Time For Everything
MAIL ENTRY FORM TO: FLORA ACADEMIC FOUNDATION, ATT: MELANIE PEARCE, 126 LINCOLN AVE., FLORA, IL 62839 OR DROP OFF AT: FCUSD #35 UNIT OFFICE, 444 SOUTH LOCUST, FLORA, IL 62839

OTHER CONTACT INFORMATION: pearcelaw@msn.com OR CALL (618) 508-2755