Registration Form

Delta Kappa Gamma presents the 11th Annual

Beat the Clock against Breast Cancer

5K Run and 2-mile Walk

Stone Harbor, NJ

DATE:   Saturday, September 28, 2013            TIMES:   Registration begins at 8:15 am

PLACE:    96th & 1st Avenue                                            5K Run at 9:00 am

                Stone Harbor, New Jersey                               2-mile Fun Walk at 9:05 am

COURSE:  Flat, fast run on smooth residential roads in the scenic shore community of Stone Harbor. 

FEATURES:  T-shirt to first 150 registered.  Approx. $500 in prizes.  Ample parking, restroom facilities, accurate 5K course, water on the course, refreshments after the race.  This event is sanctioned by USA Track & Field.

AWARDS:  Awards, including medallion, to the top Males & Females Overall and in each age group: 19 & under, 20-29, 30-39, 40-49, 50-59, 60 & over.  NO DUPLICATIONS.  Door prizes to walkers.

TO ENTER:  Send entrance form & check payable to Delta Kappa Gamma to 306 84th St., Stone Harbor, NJ  08247, or bring it with you to the race.

ENTRY FEE:  $15.00 if postmarked by 9/15, $18 after.  Kids 12 & under $10.

FOR INFO:  Rita Tice (609) 465-1852 ext. 5548 or ritaltice@gmail.com.   Please no phone registrations.

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Please check one: [   ] 5K  [   ] Fun Walk           Are you a survivor?    Yes      No

Name: _________________________________________________

Mailing Address: ____________________________________________________

e-mail _____________________________________________________________

Sex (circle):   Male        Female         Age on Race Day: _____   

Tee shirt size (circle):    S     M    L    XL    XXL

Waiver.  Please read carefully and sign.  In consideration of the acceptance of this entry, I hereby, for myself, my heirs, my executors and administrators, waive any rights and claims for damages I may have against the sponsors, coordinating groups and individuals associated with the event, their representatives, successors and assigns and will hold them harmless from any injury suffered in this event.  Also, none of the above are responsible for the loss of personal items nor any other form of aggravation in connection with said event.  I have been warned that I must be in good health to participate in this event.  I also give permission for free use of my name and picture in any broadcast, telecast or print media account of this event.  No one may enter this event without signing this waiver and completing an entry form.

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Signature of Participant*   (*OR parent signature required if entrant is under 18)