2007 Lake Side 5k Walk Contribution Form

Registration Form

Please print - Please submit by September 30,2009

Name: _________________________________________________
Address: _________________________________________________
City: ___________________________ State: _____ Zip Code: ________
Telephone: ___________________________ Age: _____
Team Name: ___________________________________________

Shirt Size: S ___ M ___ L ___ XL ___ XXL ___

(Walkers must raise $25.00 or more to receive a t-shirt, goodie bag and to be eligible for prizes)

Please bring your completed Official Contribution Form to the walk.

My company has matching funds. My matching gift form is attached.
(Not sure? Check with your employer.)

I cannot participate, but please accept my donation of $__________


Make checks payable to: Mail to: Questions?	Special Olympics Westmoreland County PO Box 547 Greensburg PA 15601 Call: 724-837-6111

I hereby waive all claims against the Greensburg Y.M.C.A. and Special Olympics Westmoreland County, sponsors and other personnel for any injury that I might suffer at this event. I attest that I am physically fit and prepared for this event. I grant full permission for organizers to use photographs and quotes from me in legitimate accounts and promotions of this event.

_____________________________ Date ________ ________________________________
Signature	Parent or Guardian if under 18

Please photocopy this form and pass it on to others so they may participate.

The official registration and financial information of Special Olympics Pennsylvania Inc. and the Greensburg Y.M.C.A. may be obtained from the Pennsylvania Department of State by calling toll free, within Pennsylvania, 1-800-732-0999. Registration does not imply endorsement.



October 10, 2009 - Rain or Shine