2nd Annual Fundraiser for Keokuk Class of 2018 Parents for a Safer After Prom

October 22, 2016 KHS U Drive Rain or Shine Registration at 8:00 am, 5K (run/ walk/drag) starts at 9:00 am

Registration fee: $25 (register prior to October 7 to guarantee a t-shirt) Name:_______________________________________________________________________________ Address:_____________________________________________________________________________ Phone: (______)___________________________ Email:____________________________________ T-Shirt size: YS

YM

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AM

AL

AXL AXXL

By my signature I, for myself/ representative, declare full responsibility of myself during my participation in the Keokuk Class of 2018 Parents for a Safer After Prom 5K. Furthermore, I waive and release any and all claims for damages against this organization, and any other representatives for any injury I may sustain in connection with this event. Parent or Guardian must sign if entrant is under 18 years old. Signature:_______________________________________________________Date_________________ Send registration Form and check to: Amanda Walrath, 2462 Johnson Street Road, Keokuk IA 52632 (217) 430-3453 **Checks payable to Parents for a safe prom

October 22, 2016 KHS U Drive Rain or Shine Registration at 8:00 ...

Rain or Shine. Registration at 8:00 am, 5K (run/ walk/drag) starts at 9:00 am. Registration fee: $25 (register prior to October 7 to guarantee a t-shirt). Name: ...

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