One Entry per Form-Please Fill Out Completely
Run sponsored in part by:
Fort Madison Family YMCA’s Rodeo Stampede 5k Run/Walk
Saturday, September 11th, 2010
Registration Form
Deadline for Advance Registration is Friday, September 3rd, 2010.
Register early to receive your requested T-shirt size!!
Registration begins at 7:00 a.m. on day of event in Central Park at 9th & Avenue F.
Events start at 7:45 a.m.
Youth Run (12 and under) — 1/2 mile Adult Race — 5k
(All youth receive a medal for participating) (Winners in each age category will receive a trophy)
Advance Late
Registration Fee: $15.00......................$20.00
Adult T-Shirt Size (circle one): S M L XL
Youth T-Shirt Size (circle one): S M L
Age (as of September 11,2010): _______ Sex (circle one): Male Female
Name:__________________________________________________________________
Please Print Clearly
Address:________________________________________________________________
Please Print Clearly
________________________________________________________________
City State Zip
Phone: (______)__________________________ Email: ________________________
By my signature I, for myself/representative, declare full responsibility of myself during my participation in the Fort Madison Family YMCA Rodeo Stampede Run/Walk. Furthermore, I waive and release any and all claims for damages against the City of Fort Madison, Fort Madison Family YMCA and the Tri-State Rodeo, and any other representatives for any injury I may sustain in connection with this event.
Parent or Guardian must sign if entrant is under 18 years old.
Send Registration Form and Check to:
Fort Madison Family YMCA Stampede
c/o Fort Madison Family YMCA
220 26th Street
Ft. Madison, IA 52627
*Checks Payable to Fort Madison Family YMCA
For more information, please call Ryan @
319-372-2403 ext. 4
Registration forms can also be found at:
www.ymcafm.com
Signature:____________________________
