Twelfth Annual 5K Run For Erin
Race Date: September 24, 2011, 7:30 am
Fee: $20 pre-reg; $25 race day reg.

Registration Form (please print)
Age: _________ Male: __ Female: __
Participant's Name: _______________
Address: _______________________
City: ___________ State: ____ Zip:______
Home Phone: ____________________
Email Address: ___________________
Employer: _______________________
Work Phone: ____________________
Occupation: _____________________
Work Fax: ______________________

(Ask your employer about a matching gift program)

Waiver of Liability Must Be Signed
I agree to participate in the National MPS Society Walk/5K run. I hereby signify that I understand that the National MPS Society, it's local volunteer representatives and all other organizations persons and sponsors connected with this event are not to be held responsible for any injuries which I might suffer while taking part in this event or as a result thereof. In this connection, I hereby waive any claims or damages to my person or property. I also grant permission to all the foregoing to use photographs, videos or audio recordings of the event for any legitimate purpose.

________________________________             __________
Signature (parent/guardian signature if under 18)   Date

Print and mail registration fees by 09-17-10 to:
"Run For Erin"
4223 Osprey Pointe
Woodstock, GA 30189        (770) 928-0853

__MY EMPLOYER WILL MATCH THIS GIFT, ENCLOSED IS A MATCHING GIFT FORM.
The official registration and financial information of The National MPS Society, Inc. may be obtain ed from The Penmnsylvania Department of State by calling toll free, within Pennsylvania, 1(800) 732-0999. Registration does not imply endorsement.

The National MPS Society, Inc.
www.mpssociety.org