Registration Entry Form To register, please visit MPMFoundation.org (search from Events tab) or fill out the form below. For more information, call (727) 725-6718.
Morton Plant Mease Foundation Prostate Cancer Awareness Race - 10K, 5K, Miracle Mile and Kids Dash September 8, 2012 - Morton Plant Hospital campus Last name ________________________________________________ First name _________________________________________ MI _____________________________ Mailing address _________________________________________________________________________________________________________________________________ City __________________________________________________ State ___________________________ Zip _____________________________________________________ Date of birth ______________ Age (on 9/8/12) ________ Sex q M q F Daytime phone (_______) __________– _______________________________________ E-mail ___________________________________________________________________________________________________________________________________________ T-shirt size (check one) ADULT: q S q M q L q XL q XXL YOUTH: q S q M q L q I am a prostate cancer survivor. Emergency contact (first and last name) ________________________________________________________________________________________________________ Relationship __________________________________________________________ Phone (_______) __________– ______________________________________________
Entry Fees Please circle the race you are registering for. 10K and 5K - $25 (through 8/31); $30 (9/1 through 9/7); $35 (race day) Miracle Mile (1-mile run/walk) - $15 (through 8/31); $20 (9/1 through 9/7); $25 (race day) Kids Dash - $10 (through 9/8)
Payment Method Credit Card: q Visa q MasterCard q American Express q Discover Card # ___________________________________________________ Signature _______________________________________________________________________ Exp. date: ______________________________________ Security code on back (front on Amex) of card: ___________________________________________ Check # ________________ (payable to Morton Plant Mease Foundation) Mail application to: Morton Plant Mease Foundation, 1200 Druid Road S., Clearwater, FL 33756 By signing and submitting this entry form, I indicate my agreement to the following conditions: (1) Entry fees are nonrefundable; (2) Entries cannot be transferred to other athletes; (3) Race management reserves the right to cancel or modify the event due to unfavorable conditions; (4) Race management reserves the right to accept or reject all entry forms; (5) I agree to have my photo taken and I understand that it may be used for event purposes.
________________________________________________________________________________________________________ __________________________________ Signature of applicant
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________________________________________________________________________________________________________ __________________________________ Signature of parent/legal guardian for participants under age 18
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Register online using our Events tab at MPMFoundation.org.
July/August
35
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