1st Annual Artwork by Shelby SUPER HERO 5K Run and Fun Run/Walk Benefit for students with Autism in Monroe & Randolph Counties October 18, 2014 5K Start: 8:00am Fun Run/Walk Start: 8:49am Location: Gardner Elementary School, 200 Rogers Street, Waterloo, IL Capes, Suits and other Super Hero attire encouraged! Show us your Superpower! 5K Race Divisions for Male and Female participants: **Top Male and Female Overall** Awards: Entry Fee: Course: 10‐19 20‐29 30‐39 40‐49 50‐59 60‐69 70 & Over Heavy Weight for 225+ pounds The top 3 finishers in each age division will receive medals. $20.00 if postmarked by October 10, 2014. Late and race day entries ‐ $25.00. Race T‐shirts guaranteed for those entries postmarked by October 10, 2014. City streets with rolling hills, out and back. Race will be held regardless of the weather, delayed start for dangerous weather. Fun Run/Walk: 0.4 miles Entry Fee: FREE Please submit a registration form Everyone is welcome to join us! This is an inclusive event and all participants will earn a medal. For questions visit www.theautismreality.org or contact Darcy at 618.939.5650, dfausz@roe45.org or Stacie at 618.587.2326 ext. 119 shick@perandoe.org. _____________________________________________________________________________________________ Our goal is to raise awareness for Autism and Autism Spectrum Disorders and also offer an event that students can actively participate in. All monies raised stay in Monroe & Randolph counties to support our students with Autism. StAR is a subcommittee of The Maidez Center which is a 501(c)3 tax exempt nonprofit organization 5K Race Day Registration and Packet Pick up: 6:45 – 7:30am Fun Run/Walk Participants arrive by: 8:30 am The awards presentation and attendance prizes will be awarded after the Fun Run/Walk. Refreshments will be provided before and after the race and fun run/walk. Bathroom and Changing Areas are available at Rogers Elementary School __________________________________________________________________________________________________ REGISTRATION FORM 1st Annual SUPER HERO 5K Run and Fun Run/Walk Name: Artwork by Shelby Address: City: State/Zip: Email Address: 5K Run Only – Age (race day) Phone #: Payment must be paid before packet will be issued. Capes, Suits and other Super Hero attire encouraged! Show us your Superpower! 5K Race Fees: $20.00 if postmarked by October 10, 2014, includes T‐shirt. $25.00 Late (AFTER October 10th) and race day entries. Fun Run/Walk FREE T‐Shirt Only ‐ $10.00 Shirt Size: ADULT S Number of participants in your group # of shirts x $10.00 = Mark # and sizes below M L XL XXL CHILD S M L XL XXL Make checks payable and mail to: The Maidez Center, 107 E. Mill Street, Waterloo, IL 62298 Waiver of Liability: In consideration of this entry, I the undersigned, intending to be legally bound hereby to myself, heirs, executors and administrators, waive and release any and all rights and claims for damages I may have against The Maidez Center, the Waterloo School District, the City of Waterloo and Monroe County and its representative, successors, assignees and all sponsors for any and all injuries suffered by me in said event. Signature: ________________________________ Date: _____________ Signature of Parent or Guardian if under 18 years of age: _________________________________ For questions visit www.theautismreality.org or contact Darcy at 618.939.5650, dfausz@roe45.org or Stacie at 618.587.2326 ext. 119, shick@perandoe.org. StAR is a subcommittee of The Maidez Center which is a 501(c)3 tax exempt nonprofit organization