Carlinville United Methodist Church & Cross Church Saturday October 6, 2012 at the Carlinville United Methodist Church Check-in begins at 7:00 1 Mile Fun Run/Walk begins at 8:00 am 5K Run/Walk begins at 8:30 am 1 Mile Entry Fee: $15.00 adult; $10.00 15 & under 5K Entry Fee: $20.00 adult; $15.00 15 & under Prizes: $25 prize to each overall male & female winner for both 1 Mile & 5K races Guaranteed t-shirt if entries received by September 21, 2012 Rain or Shine, no refunds ALL PROCEEDS GO TO CARLINVILLE AREA MISSIONS -- Donations Also Accepted Thank you for participating

********************************************************************************* ************************** Complete the following registration and return with payment to the address below—1 form per person Name__________________________________________ Address___________________________________________ City______________________ State______________ Zip_____________ Phone___________________________ Email address_____________________________________ Age of Registrant__________________ Male / Female T-shirt size: Adult _____S_____M_____L_____XL_____2XL Youth ____S_____M_____L Make checks payable to: Carlinville United Methodist Church c/o Miles for Missions Mail to: Carlinville United Methodist Church c/o Miles for Missions PO Box 466 Carlinville, IL 62626 Release/Waiver Statement: Please read carefully, sign and return this with registration. I hereby, for myself, my heirs, executors, administrators, assigns & anyone entitled to act on my behalf, release & discharge the sponsors, churches, directors, officials, employees & volunteer of the Miles for Missions Run Run-Walk from any kind of illness or damages suffered by me as a result of my participation in, or traveling to or from the 5K run/walk & 1 mile fun run/walk. I know & understand that participating may be hazardous. I should not enter unless I am medically able & properly trained. I assume all risks associated with participating in this event including falls, contact with other participants, the effect of weather, traffic & conditions to roads; all such risks being known are appreciated by me. I realize that running & walking are strenuous activities which require proper physical conditioning. I do hereby certify that I am in such physical condition and in good health. Signature of Participant: ___________________________________ Date:____________________________ Signature of Parent or Guardian (if under the age of 18): __________________________________________________________