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!