EVENT REGISTRATION FORM

Transcription

1 EVENT REGISTRATION FORM Please complete the registration form and forward it, along with your registration fee, to the Four Diamonds office or register online at FourDiamonds.org * Early Bird Registration deadline is September 5, 2011 (Event t-shirt is guaranteed to Early Bird registrants.) * Online registration ends September 23, 2011 Name Date of Birth age on day of event Gender: (circle one) Male or Female Address City StatE Zip Phone Participant s SignatuRE Date If under 18, Parent/Guardian SignatuRE Date Emergency Contact Name & Phone Number Adult T-shirt size only: (circle one) S M L XL XXL * Children under 10 will not receive a t-shirt I am registering as a 5K runner in the following division: (circle one) 14 and under I am registering as a walker. I am registering as a Team Captain. Liability waiver and Photo / Video Release: In consideration of acceptance of this entry to the Four Diamonds 5K Run & Fun Walk, I waive all claims for myself, heirs and assigns against the sponsors, cooperating groups, and any individual associated with the event and I will hold them harmless of any and all injuries or illnesses that may result from my participation. I further state that I am in proper physical condition to participate in this event. I also hereby give my permission to use my name or photo in any media coverage without obligation to compensate me.

2 EVENT DETAILS: Support the mission of The Four Diamonds Fund of conquering childhood cancer by joining us for the 2011 Four Diamonds 5K Run & Fun Walk, which will take place on the campus of Penn State Milton S. Hershey Medical Center. As you run or walk the last leg of the event route known as Hope Drive, you will pass the blue Hope Diamonds lining the route and understand the impact your participation has in the fight against pediatric cancer. Each diamond celebrates the life of a child or young adult who is currently battling pediatric cancer, is a pediatric cancer survivor, or is someone who courageously lost the battle. Your support is important and offers hope for a cure. LOCATION AND TIME The 5K Run & Fun Walk will begin and end at the Academic Support Building at 10:00 a.m. Penn State Milton S. Hershey Medical Center, 600 Centerview Drive Hershey, PA Pre-event packet pick-up: Saturday, September 24, :00 a.m. 1:00 p.m. Academic Support Building REGISTER: MAIL, FAX OR ONLINE: Complete the registration form and return to: The Four Diamonds Fund Office of University Development, A Centerview Drive Hershey, PA Fax: Register online at: FourDiamonds.org until September 23, 2011 Early Bird registration (Entry form postmarked by September 5, 2011) $20 Receives event t-shirt $8 Children ages 10 and under (Children will not receive a t-shirt) Late Registration (Entry postmarked after September 6, 2011) $25 $10 Children ages 10 and under Please contact the Four Diamonds office at if you have any questions.

3 U.ED. MED DEV Penn State Milton S. Hershey Medical Center Office of University Development, A Centerview Drive, P.O. Box 852 Hershey, PA

4 U.ED. MED DEV 2011 FOUR DIAMONDS 5K RUN & FUN WALK Sunday, September 25, :00 a.m.

5 5K RUN AWARDS & PRIZES Awards and prizes will be awarded following the race to: Top three finishers in each age group Top overall male Top overall female Prizes do not overlap You must be present to collect your prize 2011 FOUR DIAMONDS 5K RUN RESULTS Complete results will be posted within hours on pretzelcitysports.com 5K RUN COURSE MAP The course for the 5K Run will take place on the campus of Penn State Milton S. Hershey Medical Center. The race starts and finishes at the Academic Support Building. Race timing is provided by Pretzel City Sports. To view and download the 5K Run course map go to FourDiamonds.org TEAM AWARD The team raising the most money will be recognized at the event. Register your team and create your own team page online at FourDiamonds.org To qualify for the team award: Each team member must raise a minimum of $100 with a minimum of $1,000 raised/team. Team members can be runners and/or walkers Team donations must be received by the Four Diamonds office by Noon on Friday, September 23, 2011, at which time each team member will receive an event t-shirt. Honorary Chairperson Diondra Laban-King

6 About The Four Diamonds Fund The Four Diamonds Fund The mission of The Four Diamonds Fund is to conquer childhood cancer by assisting children treated at Penn State Hershey Children s Hospital and their families through superior care, comprehensive support, and innovative research. Founded in 1972 by Charles and Irma Millard, The Four Diamonds Fund has aided thousands of children and their families from central Pennsylvania and surrounded areas by providing programs and services that offer financial, medical and emotional support as they face the challenges of pediatric cancer. The Fund offers support in the following ways: covers all expenses of the child s care and treatment not paid for by insurance or other means. supports medical staff members who provide comprehensive medical care through a team comprised of pediatric oncologists, nurse specialists, social workers, child life specialists, a clinical nutritionist, a clinical psychologist, and a music therapist. supports pediatric cancer research conducted at Penn State College of Medicine, where the focus is better treatments and hopefully a cure for pediatric cancer. THANK YOU FOR YOUR SUPPORT Thanks to the tremendous support of event participants, business sponsors, and volunteers, the annual Four Diamonds 5K Run & Fun Walk has raised more than $72,000 for The Four Diamonds Fund. With your continued commitment and support, we can and will make a difference in the fight against pediatric cancer.

7 2011 FOUR DIAMONDS 5K RUN & FUN WALK SPONSORSHIP OR TEAM FORM: (Please duplicate or download an additional sponsorship or team form at FourDiamonds.org) Consider asking friends, relatives, neighbors, and local businesses to sponsor you for this event and help conquer childhood cancer. Please complete this form and return all donations on or before September 23, Please make checks payable to The Four Diamonds Fund. *Matching Gifts Please remember to include the donor s personal check, made payable to The Four Diamonds Fund, and the employer s completed matching gift form in order for us to process a matching gift. Participant s Name: my fundraising goal: $ Donor s Name Address City, State, Zip Address Phone Amount * Matching Gift

8 REGISTRATION FORM CONTINUED Early Registration for 5K Run/Fun Walk (Postmarked by Sept 5, 2011 receive an event t-shirt) $20 $ $8 Children 10 years and under $ Late Registration for 5K Run/Fun Walk (Postmarked on/after Sept 6, 2011 do not receive an event t-shirt) $25 $ $10 Children 10 years and under $ $30 I would like to sponsor a diamond along Hope Drive in honor of $ $30 I would like to sponsor a diamond along Hope Drive in memory of $ I cannot participate in the event but would like to make a donation to The Four Diamonds Fund in the amount of: $100 $250 $500 $1,000 Other $ Total amount enclosed $ Payment options: Check (Payable to The Four Diamonds Fund.) Credit Card Visa Mastercard AmEx Discover Credit Card # Exp Date: Signature: Please forward your completed registration form and payment to: The Four Diamonds Fund Office of University Development, A Centerview Drive, PO Box 852 Hershey, PA phone fax FourDiamonds.org