REGISTRATION
$25 per person or $20 per person for a team (Team must consist of minimum 10 participants. All team registration forms and payments must be submitted together.)
Print this form and mail with check made out to United Way of Southern Kentucky to:
United Way of Southern Kentucky
P.O. Box 3330
Bowling Green, KY 42102
or fax to 270-843-3236 to pay the day of the event with cash or check
* indicates required field
Name* ___________________________________________________________
(First) (Last)
Address* _________________________________________________________
(Street) (City) (Zip)
Phone Number* ____________________________________________________
(Area Code) (Number)
Email* _____________________________________________________________
Team Name ________________________________________________________
Teams must consist of a minimum of 10 participants and Team Name must be listed to qualify for team prizes.
In which group will you compete?* (Circle one) Male: 18-29 30-39 40-49 50+
Female: 18-29 30-39 40-49 50+
Must choose appropriate answer for age as of October 2, 2010. Verification may be required.
Winners will be announced at conclusion of event. You will be contacted via email or phone if you win in your age category, if you are an overall winner, or if you are part of a winning team.
Please select your t-shirt size* (Circle one) S M L XL XXL XXXL
Size not guaranteed
You must read and sign the Release and Waiver of Liability Form at the registration table at the event to complete your registration.
A copy of this waiver can be found on the Liability Waiver page.
Circle one:
Check or cash enclosed (qualifies for free WIPEOUT t-shirt)
I will pay the day of the event (WIPEOUT t-shirt not included)
For internal use only:
Paid via: • Check # _______________ • Cash
Initials: __________ Date: ___________