This One’s for
the “Ghouls”
Fun Run/ Walk (2 miles)
Join us for a Halloween Fun Run around
scenic Pine Lakes to raise money for Breast
Cancer Awareness.
When: October 29, 2011
Registration: 9 a.m.
Start Time: 10 a.m.
Where: Pine Lakes (1405 Lakeview Heights Pittsfield, IL)
Cost: $10 Early Registration Fee
$5 Kids 12 and under (2 and under are free)
$15 Day-of Registration Fee
Download a registration form online or stop
by Illini Therapy & Fitness
before Oct. 17th to
guarantee a free t-shirt
www.illinihospital.org
Wear Your Costumes and Win!
• Most original to the breast cancer awareness cause (please remember this is
a family event)
• Spookiest
• Best Kid Costume (12 and under)
128 W. Washington St. • Pittsfield, IL
This One’s for
the “Ghouls”
Fun Run/ Walk (2 miles)- Oct. 29th
Last Name: ____________________ First Name:_________________________
Address:_______________________ City:__________________ State: _____
Zip: ___________ Phone: _____________ Age on Race Day: ______
Race Shirt Size (Guaranteed if registered by Oct. 17th)cotton long sleeve t-shirts
S
M L
XL 2XL
Kids shirt size (cotton long sleeve t-shirt):
S (6-8)
M (10-12)
L (14-16)
$10 if registered by Oct 17th $______ / $15 on race-day $______
$5 Kids 12 and under $______
Make Checks Payable to:
Illini Therapy & Fitness
RELEASE AND WAIVER OF LIABILITY: I, on behalf of myself, my personal representatives, heirs, executors,
administrators, agents, and assigns, HEREBY RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO
SUE ILLINI THERAPY AND FITNESS, its governing board, directors, officers, employees, agents, and volunteers, (hereinafter referred to as "Releasees") for any and all liability, including any and all claims, demands, causes of
action (known or unknown), suits, or judgments of any and every kind (including attorneys' fees), arising from any
injury, property damage or death that I may suffer as a result of my participation in the Activity, REGARDLESS OF
WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES, UNLESS THE INJURY
DAMAGE OR DEATH IS CAUSED BY THE RELEASEES’ NEGLIGENCE OR INTENTIONAL ACTS, AND
REGARDLESS OF WHETHER THE INJURY DAMAGE OR DEATH OCCURS WHILE IN, ON, UPON, OR IN
TRANSIT TO OR FROM THE PREMISES WHERE THE ACTIVITY, OR ANY ADJUNCT TO THE ACTIVITY,
OCCURS OR IS BEING CONDUCTED. I further agree that the Releasees are not in any way responsible for any
injury or damage that I sustain as a result of my own negligent acts.
Signature
Date Parent Signature if under 18 Date