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MARTY’S MUSTANG SCAMPER 5K RUN/WALK
All Proceeds benefit the LC High School Baseball Program
Saturday, April 11, 2015 – Rain or Shine
8:00 AM
Van Lieshout Park
Registration Form
One registration form is required per participant. Additional Registration Forms available on
www.littlechutediamondclub.com
I plan to: _____Run
____Walk
Last Name ______________________________First Name______________________
Address________________________________________________________________
City____________________________________State_____________Zip___________
Phone__________________________________Email___________________________
Date of Birth____/____/________Gender_____________________________________
T-Shirts will be provided to all pre-registered runners. Those registering on race day will receive shirts on a firstcome first-served basis. Available sizes are:
YOUTH:
S
M
L
ADULT:
S
M
L
XL
XXL
(Circle One)
Payment
____Adult Pre-registration until 4/4/14
$20.00
____Adult Pre-registration after 4/4/14
$25.00
____Youth 17 & Under
$15.00
Sub-Total
My Personal Donation to support High School Baseball
Total
________
________
________
___Enclosed is my check for $_________ payable to: Little Chute Diamond Club and send to:
Little Chute Diamond Club, 3345 Streamview Lane Appleton, WI 54913 or Drop Off at Little Chute Park &
Rec Dept – 1940 Buchanan Street, Little Chute
Waiver: I hereby declare, assert and affirm that my participation in Marty’s Mustang Scamper 5K Run/Walk is done
having knowingly and voluntarily assumed ALL RISKS involved in this Special Event.
Print Name___________________________________ Date _____________________________
Signature______________________________________ Parent/Legal Guardian must sign if
participant is under the age of 18
***For Questions email Head Coach Dean Birling @ DBirling@belronusa.com or call 920-740-6121***