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Base Registration $ ___________________________
$ ___________________________
Total Dollar Amount Enclosed $ ___________________________
OFFICE USE ONLY
Team Code # __________
Check # ______________
Bib # ________________
Date Rec’d ___________
IA03005-MF/2013
Zip Code Female
Last Name First Name
Street Address
City State
Phone ( ) - Date of Birth / /
Male
Age on 5/07/16
*E-Mail (Required) ____________________________________ Team _________________________________________________
Volunteer — Please call Bridget Swanstrom at (641) 777-7096 to volunteer Race Day.
Sponsorship — I’m interested in future sponsorship details. Contact me at (name/phone number) _____________________________________________________________
Early Registration (online or postmarked by 4/13/16)
Regular Registration (online by 5/5/16; at Park 5/06/16)
Race Day Registration (Race Day 5/07/16)
*Des Moines Registration (Race Day 10/29/16)
TIMED—5 K Event TIMED—5 K Event TIMED—5 K Event TIMED—5 K Event
UNTIMED—5 K Event UNTIMED—5 K Event UNTIMED—5 K Event UNTIMED—5 K Event
1 Mile Walk
1 Mile Walk
1 Mile Walk
Adult (Over 18)
Timed Untimed
$22 $20
$27 $25
$32 $30
$10 Kids Fun Run Children are eligible to participate in the other events, but they must pay both registration fees to
receive an Event t-shirt. If an adult size shirt is needed, please indicate sizes in the yellow section above.
YS YL Fun Run Shirt
Circle the amount of your base registration
$10 $25 $50 Other I’d like to make an additional donation of Make checks payable to:
Komen Iowa Race for the Cure®
We would like to celebrate with YOU!
Please check the box to participate in the
survivor celebration on Race Day!
Survivors are welcome to join other
survivors in the shelter.
Survivors - check to be recognized
Number of years you have been a survivor
MAIL RACE ENTRY FORMS TO: Komen Iowa Race for the Cure® - Ottumwa P.O. Box 8468 — Des Moines, IA 50301
DO NOT MAIL AFTER 4/28/16Late registration may be completed on the day of the race. Registration Table is located in “Tent City” northwest of the shelter.
Participant’s Name PRINTED SIGNATURE Parent/Guardian’s Signature (if under age 18) Date
Event Shirt Size (Sizes not guaranteed - size quantities limited) YM S M L XL XXL XXXL
1 Mile Walk $24 $20
2016 Susan G. Komen Iowa Race for the Cure - Ottumwa Official Entry Form One person per entry form. Photo copies are acceptable. Please print clearly.
*Additional discounted registration for those who wish to attend the RFTC event in Des Moines on October 29!