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
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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):
__________________________________________________________