4th ANNUAL
$1,000 Scholarship T-Shirts Food & Fun
Door Prizes Raffles Medals & Awards
4th ANNUAL
Hosted by Fairmont Girls Basketball When: SUNDAY April 17th, 2016 8:00am Cost: $25 pre-registration $35 after 3/1/15
Where: The Trent Arena Fairmont High School 3301 Shroyer Road Kettering, OH 45429
Children 5 & under are FREE
Register online at keysports.neT Please join us on this special day to celebrate the life of Melissa Fortener McLaughlin. There will be a balloon launch at the completion of the race in her honor. Registration will begin at 7:00am on the morning of the race. Make all checks payable to: Fairmont Athletic Boosters. Mail forms and payment to: Lacy Drake, 3301 Shroyer Road, Kettering, OH 45429. All proceeds go to the Fairmont Girls Basketball Program. All are welcome … runners and walkers of all ages, children, and dogs! Come out and enjoy a fun-filled morning to honor Melissa! Have questions? Please contact Lacy Drake at [email protected]. T-shirts are only guaranteed to those who PRE-REGISTER for the race!
Name: ______________________________________________
Age: ____________ DOB: ___/___/_____
Address: ____________________________________________________________________ Email: ______________________________________________ Phone Number: (______) _____________________________ Shirt Size (circle one):
S
M
Gender (circle one):
Male
Female
L
XL
XXL
XXXL
Grade (high school students): 9th 10th 11th 12th Emergency Contact: __________________________________ Phone Number: (_____) _________________________ In consideration of your accepting this entry, I, the undersigned, intending to be legally bound hereby, for myself, my heirs, my executors and administrators, voluntarily assume all risks of injury to my person and damage to my property; agree to abide by all ordinances of the City of Kettering and all rules, regulations, and directions, if any, of this event; waive and release any and all rights and claims for damages I may have against Fairmont Athletic Boosters, City of Kettering, Key Sports and Business Promotions, their representatives, employees, officials, volunteers, successors, and assigns for any and all injuries and damage to me or my property in said event; and agree to indemnify defend and hold those same organizations and individuals harmless from any claims for injury or damage to myself and to third persons or their property from this event. I attest and verify that I am physically fit and have sufficiently trained for the completion of this event, and my physical condition has been verified by a licensed medical doctor. I hereby authorize Fairmont Athletic Boosters, Key Sports, and any news media, radio, movie, or TV producer, having permission from or acting for the benefit of Fairmont Athletic Boosters to show and reproduce my name, photograph, pictures, and films taken of me by any of those mentioned above.
___________________________________________________ Signature REQUIRED by ALL applicants (parent or guardian must sign if under the age of 18)
________________ Date
Door Prizes Raffles Medals & Awards
4th ANNUAL
Hosted by Fairmont Girls Basketball When: SUNDAY April 17th, 2016 8:00am Cost: $25 pre-registration $35 after 3/1/15
Where: The Trent Arena Fairmont High School 3301 Shroyer Road Kettering, OH 45429
Children 5 & under are FREE
Register online at keysports.neT Please join us on this special day to celebrate the life of Melissa Fortener McLaughlin. There will be a balloon launch at the completion of the race in her honor. Registration will begin at 7:00am on the morning of the race. Make all checks payable to: Fairmont Athletic Boosters. Mail forms and payment to: Lacy Drake, 3301 Shroyer Road, Kettering, OH 45429. All proceeds go to the Fairmont Girls Basketball Program. All are welcome … runners and walkers of all ages, children, and dogs! Come out and enjoy a fun-filled morning to honor Melissa! Have questions? Please contact Lacy Drake at [email protected]. T-shirts are only guaranteed to those who PRE-REGISTER for the race!
Name: ______________________________________________
Age: ____________ DOB: ___/___/_____
Address: ____________________________________________________________________ Email: ______________________________________________ Phone Number: (______) _____________________________ Shirt Size (circle one):
S
M
Gender (circle one):
Male
Female
L
XL
XXL
XXXL
Grade (high school students): 9th 10th 11th 12th Emergency Contact: __________________________________ Phone Number: (_____) _________________________ In consideration of your accepting this entry, I, the undersigned, intending to be legally bound hereby, for myself, my heirs, my executors and administrators, voluntarily assume all risks of injury to my person and damage to my property; agree to abide by all ordinances of the City of Kettering and all rules, regulations, and directions, if any, of this event; waive and release any and all rights and claims for damages I may have against Fairmont Athletic Boosters, City of Kettering, Key Sports and Business Promotions, their representatives, employees, officials, volunteers, successors, and assigns for any and all injuries and damage to me or my property in said event; and agree to indemnify defend and hold those same organizations and individuals harmless from any claims for injury or damage to myself and to third persons or their property from this event. I attest and verify that I am physically fit and have sufficiently trained for the completion of this event, and my physical condition has been verified by a licensed medical doctor. I hereby authorize Fairmont Athletic Boosters, Key Sports, and any news media, radio, movie, or TV producer, having permission from or acting for the benefit of Fairmont Athletic Boosters to show and reproduce my name, photograph, pictures, and films taken of me by any of those mentioned above.
___________________________________________________ Signature REQUIRED by ALL applicants (parent or guardian must sign if under the age of 18)
________________ Date
