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[Memorial Lawn Signs]


Freedom Run Registration Form

Print and complete this form. Please submit separate forms for each participant. Send it along with registration fee to address on form Or register online by selecting an event below:
Name First Last
  Male    Female 
 Address (Include Apt. No.)    
 City  
 State  Zip Code
 E-mail
 Telephone
 I will be
  Running 2 miles in age division
        13 & under  14-19  20-29  30-39  40-49  50-59  60-69  70-79 80 & older
  Running 5 miles in age division
        13 & under  14-19  20-29  30-39  40-49  50-59  60-69  70-79 80 & older
  Walking (Family name, if entering as family) __________________________________________
      (Please staple all family member registrations together and send with the fee.)

 T-Shirt size (check one) 
             Youth   (size 10-12)         
             Adult    S       M      L       XL       XXL
              (T-Shirts guaranteed to every participant who registers before June 18, 20010)

   
In Memory of Lawn Signs
 
Help decorate the first 1/4 mile of the race course, and at the same time, pay tribute to a loved one by purchasing a lawn sign in memory of their life. Participate in the Freedom Run by running/walking or purchasing a lawn sign.
The proceeds from the "in memory of" lawn signs will be given to HALO-Hope After Loss Organization, the St. Nicholas Hospital Hospice Department, or help to fund St. Nicholas Community Education progrmas and outreach initiatives.
Memory lawn signs are available for $250.
 
   
In Memory of: _____________________________________________________
   
Please select where you would like the proceeds from your memory lawn sign to to:
 

HALO - Hope After Loss Organization
St. Nicholas Hospital Hospice Department
St. Nicholas Hospital Community Outreach programs and outreach initiatives

Deadline to purchase a memory lawn sign is June 18, 2010.
   
 Circle One:       Master Card       Visa       Check Amount $ __________________
 Number:   ________-________-________-________ Expiration Date: _________/_________


In consideration of the foregoing, I for myself, my executors, administrators, and assignees do hereby release and discharge St. Nicholas Hospital, the City of Sheboygan, Sheboygan Police Department, the Sheboygan County YMCA, and all other entities and individuals who are in any way connected with the event from any liability or claims for damages, injury, or illness arising or growing out of my participation in the St. Nicholas Hospital Freedom Run.  I represent that I have adequately trained and am medically able to participate in this event, recognize the risks of injury that accompany such participation, and acknowledge that this release is being relied upon by St. Nicholas Hospital in permitting me to participate. I grant full permission without compensation to St. Nicholas Hospital to use any photographs, recordings, or other reproductions of me participating in this event.


 Entrant's Signature
 (If minor - parent or guardian's signature)

MAKE CHECKS PAYABLE TO
St. Nicholas Hospital Freedom Run

Print and complete entry form and return to:

Communication Education
St. Nicholas Hospital
3100 Superior Avenue
Sheboygan, WI  53081

 OR YMCA
812 Broughton Drive
P.O. Box 609
Sheboygan, WI  53082-0609