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St. Patrick’s Celebration P.O. Box 64 Ireland, IN 47545-0064 http://stpat.irelandindiana.com

IRISH TROT 5K RUN/WALK. St. Patrick’s Celebration P.O. Box 64 Ireland, IN 47545-0064 http://stpat.irelandindiana.com. MARCH 16, 2013 8:00 A.M. AT IRELAND ELEMENTARY SCHOOL. REGISTRATION FORM (PLEASE FILL OUT AND MAIL WITH PAYMENT TO THE ADDRESS ON THE ADJACENT PAGE )

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St. Patrick’s Celebration P.O. Box 64 Ireland, IN 47545-0064 http://stpat.irelandindiana.com

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  1. IRISH TROT 5K RUN/WALK St. Patrick’s Celebration P.O. Box 64 Ireland, IN 47545-0064 http://stpat.irelandindiana.com MARCH 16, 2013 8:00 A.M. AT IRELAND ELEMENTARY SCHOOL

  2. REGISTRATION FORM (PLEASE FILL OUT AND MAIL WITH PAYMENT TO THE ADDRESS ON THE ADJACENT PAGE) NAME_____________________________________ ADDRESS___________________________________ CITY_____________________STATE____ZIP_______ PHONE NUMBER_____________________________ T-SHIRT SIZE: S M L XL XXL WAIVER AND RELEASE I hereby for myself, and/or my minor child (if applicable), and the administrators, heirs, and assigns thereof waive and release any and all rights and claims for damages and personal injuries, resulting from negligence, which I or my child may have against: St. Patrick’s Celebration, its officers, directors, employees, and volunteers; the organizers of the St. Patrick’s Celebration Irish Trot 5K Run/Walk; their sponsors, associates, contractors, other entrants and representatives; Dubois County, its boards, elected and appointed officials, and its employees, all for property damage or personal injury, including death that may arise or grow out of my or my minor child’s participation in the St. Patrick’s Celebration Irish Trot. I certify that I and/or my child have prepared for this event. I agree to follow the rules of this race, obey all traffic laws, avoid littering, and respect the property of others. __________________________________ __________________ SIGNATURE OF PARTICIPANT DATE _____________________________________________________ SIGNATURE OF PARENT/GUARDIAN IF PARTICIPANT IS UNDER 18 • IRISH TROT • 5K FUN RUN/WALK • ENTRY FEES • - $15 for entries received by Friday March 8, 2013 • (Fee includes T-Shirt) • $15 for entries received on March 9, 2013 or after • (T-Shirt may not be available) • PRIZES • $50 prize will be awarded to the top male and female finisher! • CHECKS FOR THE ENTRY FEE CAN BE MADE PAYABLE TO THE FOLLOWING: • St. Patrick’s Celebration • ENTRIES FOR THE RUN/WALK MAY BE MAILED TO: • Scott Meyer • 4386 W 300 N • Jasper, IN 47546 • If you have any questions, please call • 634-2512 or 661-2483 • ALL PROCEEDS FROM THE EVENT ARE DONATED TO IRELAND COMMUNITY PROJECTS

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