Registration Form – 9/24/2016 at 7:00 a.m. – Peace Presbyterian Church, Stuart, FL 34997

NAME______________________________________     MALE OR FEMALE (CIRCLE ONE)

ADDRESS__________________________________________________________________

CITY____________________STATE______ZIP__________

AGE_________

DATE OF BIRTH___________________PHONE#__________________________

T-SHIRT SIZE (CIRCLE ONE) S    M   L   XL   XXL

I Hereby express and affirmatively state that I, or my child named herein wish to participate in the above stated activity. I realize that participation in this activity involves risks of injury, including but not limited to loss of future earning capacity, loss or damage to personal property, various degrees and severity of injury, all other possible risks of injury and even death which
occur by reason of me/my child’s participation and release Leukemia & Lymphoma Society/Purple Chicks/sponsors, its agents, employees therefrom. I voluntarily choose to participate, or allow my child to participate, assuming all risks.

PARTICIPANT/PARENT/GUARDIAN_____________________________________________
DATE________________

Registration Costs: Pre-Registration (payment submitted before 9/23/15) = $30
Day of Registration = $35
Kid’s Race Registration = $5 (suggested donation)

Mail to: Sheryl Esquilin @ 13005 Meadowbreeze Drive, Wellington, FL 33414–Make checks payable to Purple Chicks

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