5th Annual MS Miles of Smiles Run/Walk — May 20, 2012 at 9:00 am, North Park, Allison Park, PA

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This race will benefit the

  

 

Registration
for the 5th Annual MS Miles of Smiles Run/Walk 2012

To register for the race on May 20, 2012, please fill out this form and mail your registration fee to the Race Coordinator (see address below).

Salutation :  Mrs.   Mr.   Ms.
First name *:
Last name *:
Address :
City :
State :
Zip Code :
Email Address :
Age on Race Day *:
Gender *:
  male   female
I will participate as *:
  runner   walker   wheelchair
in the *:
  1 mile race   5 mile race   5 K race
   
T-shirt size *:
  S   M   L   XL   XXL   Child
   
Emergency Contact
Emergency Phone
   
Please read the following paragraphs carefully.
Yes, I will participate in the MS Miles of Smiles Run/Walk
 
I will make a check for entry fee of $20
payable to National MS Society and mail it to
MS Miles of Smiles Race,
c/o Ellen Stewart
223 Greenwood Drive
Wexford, PA 15090.
   
Waiver and Release from Liability
I understand that participating in the MS Miles of Smiles event can potentially be a hazardous activity presenting risk. For consideration of participation in the event, I freely accept and voluntarily assume the risks of personal injury or property damage that may result. I, and anyone entitled to act on my behalf, waive and release from all claims and liabilities of any kind arising out of my participation even though that liability may arise out of neglegence or carelessness on my part. I agree to hold harmless the MS Miles of Smiles Organizer, National MS Society, corporate sponsors, cooperating organizations and all parties connected with this event from any liability as a result of my participation. I will permit emergency treatment in the event of injury or illness while participation and give permission to use my name and photo taken of me during the event in any promotional material, publication, or on the website. I understand that the National Multiple Sclerosis Society withholds the right to dismiss anyone that may cause disturbance. I certify that I have read and understand the intent of this waiver and release.
   
I have raised (additional) funds
in the amount of $
  Please make check payable to the National MS Society
and mail it to
MS Miles of Smiles Race
c/o Ellen Stewart
223 Greenwood Drive
Wexford, PA 15090

Race fee: $20 by May 10, 2011, after $25.
 
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