First Name   M.I.   Last Name   M F Date of Birth  // (example: 01/01/2008)

First Name   M.I.   Last Name   M F Date of Birth  //

First Name   M.I.   Last Name    M F Date of Birth  //

First Name   M.I.   Last Name   M F Date of Birth  //

Phone ()  -  E-mail address:

Home Address    CityState    Zip  

Shirt Size (Note Number of Shirts per size)    

Youth  -  S   /  M  /  L    Adult  -  S /  M /  L  /  XL /  XXL    (Enter Number of T-Shirts)

Age Group (Enter Number of Participants Per Group) - U13*   / 14-18*   / 19-25   / 25-40   / 40+    

  *due to IHSAA regulations, winners in age/gender groups will receive non-monetary awards 

  $20 Pre- registration by May 19^th ($30 After Deadline and on Race Day) Walk/Run entry fee        1 $20.00 2 $40.00 3 $60.00 4 $80.00

                                                                                               Additional T-Shirt Purchase ($8) each        No Thanks 1 $8.00 2 $16.00 3 $24.00 4 $32.00

                                                                                                     Additional Donation to Foundation         

                                                                                        Total Amount to Be Billed to Charge Card         

Payment Method (check one): M/C / AMEX  / Visa  / Disc

Cardholder Name    Card#(no dashes or spaces)    Exp Date /    (example 01/08)

By selecting the Authorization Button you are agreeing to the terms of your cardholder agreement and agreeing to the participation waiver.  The charge card is processed in house, the receipts will be emailed to you as soon as possible.  Please call at 317-841-3613 if you have any questions.  Thank you!

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