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Please either click on our logo to
register on-line OR print out this
page, complete and send in the
form below along with your check.
Please check one:
o I/we will participate in the 5K Run. (list all runners/ages)
_____________________________________________________
_____________________________________________________
o I/we will participate in the 5K Walk. (list all walkers/ages)
_____________________________________________________
_____________________________________________________
Check as many as you would like:
o Please send me ________additional sponsor sheets.
o Please send me________additional brochures. I will pass them along to friends,
family and co-workers.
o I am interested in becoming a sponsor. Please send information.
o I would like to receive more information about Crohn's disease or
ulcerative colitis.
o I would like to volunteer for the Pacesetter Race or
other chapter activities.
o I am not able to participate in the race, but would like to make a donation.
Enclosed is my check for $_____.
Name____________________________________________________
Address__________________________________________________
City___________________________ State_________ Zip_________
Phone (Home)_________________(Work)_____________________
E-mail address____________________________________________
Age (on race day)______ Sex: M F (circle one)
Waiver: I hereby waive all claims against the Crohn's & Colitis Foundation of America, sponsors or any personnel for any injury I might suffer in this event. I attest that
I am physically fit and prepared for this event. I assume all risks associated with running in this event including, but not limited to:
falls; contact with other participants; the effects of the weather, including high heat and/or humidity; traffic; and the condition of the road, all such risks being known and appreciated by me. I grant full permission for organizers to use photographs of me and quotations from me in legitimate accounts and promotions of this event.
Signature X_________________________________________
X_________________________________________________ _
Please make checks payable to CCFA and mail to:
367 E. Street Rd., Trevose, PA 19053. (215) 396-9100
philadelphia@ccfa.org
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