**REGISTRATION FORM FOR LEROY 5K RACE AVAILABLE HERE** (0000-00-00)



Leroy Old Home Day

5K RACE

Sponsored by Emmett Watson: Senior Project

JULY 4th, 2012 - LEROY, PA

Registration Opens at 8:00 AM
Race Time 9:30 AM

$10.00 Pre-Registration
$15.00 Day of Race

Please Mail Registration Form To:
Emmett Watson
2910 Route 414
Canton, PA 17724

Any Questions Call or Text 570-250-4775

All Proceeds Donated To LeRoy Community Association
T-Shirts To First 50 Registrants

Age Groups: 14 & Under, 15-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70+

Checks Can Be Made Out To: Old Home Day 5K - Emmett Watson

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Name:________________________________________
Address:_____________________________________

Phone:__________________________
E-Mail:______________________________________
Age on race day:_________
Sex:______
T-shirt size: S - M - L - XL

Waiver: In the consideration of the acceptance of the entry, I hereby waive and release any and all rights and claims for damages and injuries which I may have against all persons and entities involved in the event while participating in the LeRoy Old Home Day 5K Race. I attest that I am physically fit and prepared for this event.
SIGNATURE:___________________________________
SIGNATURE OF PARENT/GUARDIAN:___________________________
DATE:_____________________________

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