2018 rocker chair sponsorship form (pdf)

November 19, 2018 | Author: Anonymous | Category: N/A
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Download 2018 rocker chair sponsorship form (pdf)...


Lory's Place Run, Walk and Rock Rocking Chair Sponsorship

Event Pre-Registration Form This is a charitable event. Entry fees are non-refundable. Please make checks to Lory’s Place. (please print, one participant per form) Circle an Event: 5k Run

5k Walk

Circle one:



Requested donation of $150 per rocking chair may reflect gifts of an individual or a group Rocker sponsors are invited to design their own dedication signs to hang on the rockers during the race. (please print)


First/Last Name or Name of Organization:

First/Last Name: Address: City/State/Zip: Phone: Email:

Address: City/State/Zip:

Short Sleeve T-Shirt Size: (please circle) YL Adult:



L XL 2XL no shirt

Phone: Email:

Name of School Attending: Circle school level: Race Fees:


$20 “Middle of the Pack” $25 “Last Dash” $30 “Race Day”




Registered April 1 to 30 Registered May 1 to 15 May 16


There is a $2 fee for an XXL T-shirt


Total Registration Cost

In consideration for and of acceptance of this entry, I, the undersigned, intending to be legally bound, hereby, for myself, my heirs, executors, and administrators, waive and release any and all rights and claims for damages I may have against Lory’s Place, Hospice at Home,Inc, the City of St. Joseph, Lakeland Health, The Whirlpool Corporation, their representatives, successors, and assigns for any and all injuries or illness which may result directly or indirectly from my participation in the Run, Walk, Rock event and related activities. I further state that I am in proper physical condition to participate in this event. I authorize Lory’s Place / Hospice at Home, Inc./Lakeland Health to utilize any photographs, personal narratives, interviews, audio and video recording of my participation in any Lory’s Place/ Hospice at Home/ Lakeland Health, Inc. event for any and all purposes.



Current chip owners, please provide your seven digit chip number:

Rocking Chair is sponsored:  In honor of  In memory of Name (as it should appear on acknowledgement):

 Please make my rocking chair sign  I will create and bring my own rocking chair sign Payment: ☐ Enclosed is my check to Lory’s Place ☐ Please charge to my credit card ☐ VISA ☐ MasterCard ☐ Amex Card #:_______________________________________ Exp: ______________Security Code#: _____________ Print Name:___________________________________ Signature:____________________________________ Date:___________________ Chair supply is limited to please submitt this form with payment on or before May 11, 2018

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