Postal Code:
Email:
First Name:
Complete mailing address must be provided.
Signature of ParƟcipant
___________________________
(Parent/Guardian if under 18)
___________________________
I ___agree ____ disagree to allow the Running Room to post my name in the Race ConfirmaƟon list online.
☐ XLarge
☐ Large
☐ Cheque
☐ Medium
☐ Small
t-Shirt Size:
☐ Cash
RegistraƟon Fee:
☐ 8km Run
☐ 5km Run
☐ 5km Walk
Event:
Please make all cheques payable to:
Southern Alberta Myeloma PaƟent Society
Tax receipts will be issued for donaƟons of
$25.00 or more unless requested.
WAIVER MUST BE SIGNED:
In signing this release, I acknowledge that I understand the intent thereof, and I hereby agree and absolve harmless the Southern Alberta Myeloma Pa ent Society,
Running Room Sports Inc., corporate sponsors, coopera ng organiza ons and any other par es connected with this event in any way, singly, or collec vely from
and against blame and liability for any injury, misadventure, harm, loss, inconvenience, or damage hereby suffered or sustained as a result of par cipa on in
Mul ple Miles for Myeloma Walk/Run on July 30, 2011 or any ac vi es associated herewith. I hereby consent to and permit emergency treatment in the event of
injury or illness. I also give full permission for use of my name and photograph in connec on with the event.
Privacy Policy: Personal informa on collected on the pledge form will not be given or sold to any other organiza on and will only be used for communica on
directly related to your pledge.
Telephone:
Last Name:
Address:
City/Town:
Please PRINT clearly.
RegistraƟon Form
Register:
At any Calgary Running Room location or online at
www.runningroom.com.
Regstration Fee:
Until July13th, 2012:
Individuals: $30
Team (2-8 members per team): $25/member
For More Information:
Reanne: 403.990.1425
Carol: 403.287.7829
What is Multiple Myeloma?
Multiple Myeloma is an incurable but treatable
cancer of the plasma cell, a type of white blood cell.
Many Calgarians and Albertans have been affected
by this disease, including those who have been
diagnosed with Multiple Myeloma as well as those
who have had family members or friends who have
been diagnosed.
For more information about Multiple Myeloma
and the Southern Alberta Myeloma Patient
Society:
www.southernalbertamyeloma.org
Southern Alberta Myeloma
Patient Society
Until July 25th, 2012:
Individuals: $35
Team (2-8 members per team): $30/member
Registration includes technical t-shirt, post-race
goodies, and draw prizes.
Awards for top three donation earners and medals
for top three runners.
Race Package Pick-Up:
Thursday, July 26th 4:00 - 8:00pm
Friday, July 27th 12:00 - 6:00pm
Running Room Eau Claire Market, Calgary
Unit A01, 200 Barclay Parade SW
Phone: 403.264.4095
4th Annual
MULTIPLE MILES
FOR
MYELOMA
2011 Multiple Miles for Myeloma
All funds raised go to the University of Calgary
Division of Hematology Research
and Education Fund, specifically for
Multiple Myeloma research.
Special Thanks to Our 2012 Sponsors
Norma Gilbert
Calgary Naval Veterans
Association
Nancy & Dilip Shamanna
5 km Walk
5 & 8 km Run
Saturday, July 28th, 2012
9:00am
North Glenmore Park, Calgary
In support of local research
for Multiple Myeloma
Southern Alberta Myeloma Patient Society’s 4th Annual Multiple Miles for Myeloma DONATION FORM
Donation Earner Name: Telephone: Email:
Donor Information
Donation Amount:
Name:
$ ________
Address:
City/Province:
Telephone:
Postal Code:
Email:
□ Cash □ Cheque
□ Receipt Requested
Name:
$ ________
Address:
City/Province:
Telephone:
Postal Code:
Email:
□ Cash □ Cheque
□ Receipt Requested
Name:
$ ________
Address:
City/Province:
Telephone:
Postal Code:
Email:
□ Cash □ Cheque
□ Receipt Requested
Name:
$ ________
Address:
City/Province:
Telephone:
Postal Code:
Email:
□ Cash □ Cheque
□ Receipt Requested
Name:
$ ________
Address:
City/Province:
Telephone:
Postal Code:
Email:
□ Cash □ Cheque
□ Receipt Requested
Name:
$ ________
Address:
City/Province:
Telephone:
Postal Code:
Email:
□ Cash □ Cheque
□ Receipt Requested
Name:
$ ________
Address:
City/Province:
Telephone:
Postal Code:
Email:
□ Cash □ Cheque
□ Receipt Requested
Name:
$ ________
Address:
City/Province:
Telephone:
Postal Code:
Email:
□ Cash □ Cheque
□ Receipt Requested
Name:
$ ________
Address:
City/Province:
Telephone:
Postal Code:
Email:
□ Cash □ Cheque
□ Receipt Requested
Name:
$ ________
Address:
City/Province:
Telephone:
Postal Code:
Email:
□ Cash □ Cheque
□ Receipt Requested
Name:
$ ________
Address:
City/Province:
Telephone:
Postal Code:
Email:
□ Cash □ Cheque
□ Receipt Requested
Name:
$ ________
Address:
City/Province:
Telephone:
Postal Code:
Email:
Please make all cheques payable to: Southern Alberta Myeloma Patient Society Tax receipts will be issued for donations of $25.00 or more unless requested. □ Cash □ Cheque
□ Receipt Requested