WALK REGISTRATION

HOME CALENDAR OF EVENTS CONTACT US


Please print and use this form or email/call/write
and we will gladly provide registration forms to you

carla@aplacealongtheway.org

 "3rd Annual 5k Jingle Walk/Run"
for Homeless Youth

Seville Park. 16601 Seville Ave Fontana 92334

Registration individual....................$10
Registration family..........................$20

Please note that family registration includes
two adults and unlimited children. Only two t-shirts
will be provided per family registration.

Additional t-shirts may be purchased for $10
each based on availability.

To pre-register, please fill out the registration
form and mail it, along with your check payable
to APATW, to A Place Along the Way
1615 W. Carter St., Bloomington, CA 92316
Entries must be postmarked by November 30, 2011

Complete one form per person (copy this form if needed)
(Please print)

Name _________________________________________________

Address_______________________________________________

City______________________State______Zip______________

Phone_________________________________________________

Corp Name_____________________________________________

E-mail address________________________________________

Check here ____ to be put on APATW mailing list

I collected pledges as:

1. An Individual ____

2. A Team Member ____

Team Name or Captain___________________

WAVIER: I hereby release the A PLACE ALONG THE WAY (APATW),
the Fontana Unified School District, all personnel, any
co-sponsoring organization or agency from responsibility
for any injuries or damages I may incure as a result
of my participation in “5k Jingle Walk/Run”
I assume all risks associated with this walk/run including
but not limited to falls, traffic, condition of the sidewalk
and weather conditions. I hereby certify that I am in good
condition and am able to walk/run in this event. Additionally, I
will permit the use of my picture in broadcast, print, etc.
This entry is invalid unless signed by the entrant. If entrant
is under 18, a parent or guardian must sign entry. An adult
must accompany children under 12.

_______________________________________________
Walker/runner's Signature & date (Parent/Guardian if under 18)
(one consent form per walker/runner)

“5k Jingle Walk/Run” Pledge Form

Name Address $ Amt.

1._______________________________________

2._______________________________________

3._______________________________________

4._______________________________________

5._______________________________________

6._______________________________________

7._______________________________________

8._______________________________________

9._______________________________________

10.______________________________________

11.______________________________________

12.______________________________________

13.______________________________________

14.______________________________________

15.______________________________________

16.______________________________________

Total: $_____________________

 If pledges are paid after event:
PAYMENT OPTIONS-
CHECK OR MONEY ORDER:
Please print this form and
mail check or money order payable to

APATW
1615 W Carter ST.
Bloomington, CA 92316

Chair: Carla C(909) 200-6893
Treasurer Catherine W.