1
The 6 th Annual Archangel Michael Church & Tom Zangas Lung Cancer Foundation 5K Run/Walk with 1K Family Fun Run/Walk When : October 26 th , 2013 – 5K & 1K (9:00 am start) Check-in and race day registration opens at 8:00 am Where : Christopher Morley Park Roslyn-North Hills, Searingtown Road Awards : Male/Female winners for ages: 8-12, 13-18, 19-29, 30-39, 40-49, 50-64, 65+ Fees : $35 pre-registered, $45 on race day Includes T-shirt, post-race refreshments and snacks Course : 5K and 1K around Christopher Morley Park No bikes, skateboards, or rollerblades Benefits : The Archangel Michael Church & The Tom Zangas Lung Cancer Foundation REGISTER ONLINE OR FILL INFORMATION BELOW Go to www.archangelmichaelchurch.org and click on “5K Run” link OR Participant Information: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Age : Gender: Shirt Size: I would like to participate – Please make check out to Archangel Michael Church I cannot participate but I would like to make a donation Please charge my credit card in the amount of $__________. Signature: ____________________________ AMEX VISA MasterCard Card # ____________________________________________ Exp. Date: _____/_____/_____ Code:___________ WAIVER: I certify that I am physically fit and sufficiently trained to participate in the Archangel Michael Church 5K and 1K Run/Walk. In consideration of acceptance of my entry into the event, and recognizing that there are certain inherent risks associated with participating in an event of this type, I agree to assume that risk and indemnify, waive, release, and hold harmless the Archangel Michael Church, The Tom Zangas Lung Cancer Foundation, any sponsor(s), Port Washington, their directors, managers, officers, employees, representatives, agents, heirs and assigns from any and all claims for damages arising from or out of my participation in the event. I have read and fully understand all of the above. _______________________________________________________________________ __________________________ LAST NAME FIRST NAME ADDRESS CITY STATE ZIP PHONE For entry send your completed form and fee to: Archangel Michael Church 100 Fairway Drive Port Washington, NY 11050 516-944-3180 S / M / L / XL M / F
