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PLEASE READ & SIGN FOR PARTICIPATION I know that running or walking a road race is a potentially hazardous activity. I should not enter and run/walk unless I am medically able and properly trained. I agree to abide by a decision of a race official relative to my ability to safely complete the run. I assume all risks associated with running this event, including but not limited to: falls, contact with other participants, effects of weather, including cold, high heat or humidity, traffic and conditions of the road; all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I for myself and anyone entitled to act in my behalf, waive and release all race officials and agents; the City of Menomonie; and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event though that liability may arise out of negligence or carelessness on the part of persons named and not named in this waiver. I certify I am an amateur and eligible to participate in this competition. I permit the organizers to use photographic images taken during the event for promotional purposes.

Signature _________________________________ Guardian_____________________ (If under 18 years of age, authorized signature of guardian needed) Date

ABOUT MARTY Raised in Menomonie, WI, Marty Miller was truly unique. His frank candidness, clever wit and sly smile allowed many doors to open and many friendships to come his way easily. He was an MHS Class of „91 Grad, attended UW-Stout and worked within the community. In May, 2009 at the age of 36, Marty, his wife Andrea and their two sons learned of his diagnosis of Acute Myeloid Leukemia (AML). Marty battled through multiple rounds of chemo, a stem cell transplant and many blood transfusions. In the height of his battle he never used the words “give up”. He was always telling everyone to “Keep the Faith” and “Live Life and Fight”. The Doctor‟s anticipated Marty would not reach his 37th birthday in April , 2010. Marty had faith on his side and prior to his diagnosis, he had been running and had gotten into his best physical shape in years. This proved to give him an additional four months with his family. A summer with his sons, filled with great fun that will never be forgotten. After 17 months and two failed remissions Marty lost his battle to this horrible disease in October 2010. He is truly missed everyday. We dedicate this event to him, his fight and the hope of helping others to overcome their battle with blood cancers.

Saturday, October 1st, 2011

10:00am Wakanda Park Menomonie, WI 5K Run/Walk

GET YOUR MOJO ON! BENEFITING THE


On Saturday, October 1st, 2011, Wakanda Park in Menomonie will be the site of the First Annual Marty's Mojo 5K Run/Walk & Pig Roast. The Mojo will benefit the Leukemia & Lymphoma Society of Wisconsin in honor of Marty Miller. Registration: Register on-line at : martysmojo.zapevent.com OR by submitting the attached form & payment to: Marty’s MOJO PO Box 434 Menomonie WI, 54751 Or Drop Off At: Anytime Fitness 1700 Stout St. Menomonie, WI Please make checks payable to: Marty‟s MOJO Visit Our Website: www.martysmojo.com

Get Your MOJO On! Saturday, Oct. 1st, 2011 10:00am - Wakanda Park Menomonie, WI

REGISTRATION FEES: 5K Event ONLY $20-Before September 22, 2011 $25-After September 22, 2011 5K Event & Pig Roast $27-Before September 22, 2011 $32-After September 22, 2011 Pig Roast ONLY $7– PAPER REGISTRATION ONLY Late Registration* Friday, Sept. 30th 6pm-7pm Anytime Fitness , 1700 Stout Street, Menomonie, WI OR Saturday, October 1st , 8am-9:30am. Wakanda Park *Late day registration is accepted but does not guarantee t-shirt/goodie bag. Awards** Awards will be given to the top 3 male and female winners in all age groups. Age groups are: 14 & Under, 15-19, 20-29, 30-39, 40-49, 50-59, 60+

**Race will be Chip Timed

REGISTER TO GET YOUR MOJO ON! NAME:

ADDRESS

CITY STATE ZIP PHONE EMAIL AGE (on date of the race)

Please Circle: Male

Female

Adult

Shirt Size SM MED LG XL XXL

Child

SM MED

CIRCLE YOUR EVENT 5K ONLY 5K & PIG ROAST PIG ROAST ONLY

Living Life & Fighting For a Cure Against Blood Cancers

PLEASE SEE/SIGN WAIVER ON BACK

(OVER)

Martys Mojo Runner Registration Form  

Get Ready to Run! Marty's Mojo Registration Form is waiting for you to fill it out, send it in and get your MOJO on!

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