Printable Registration Form

Complete this form and mail it with your check, cash, or money order payable to The Emma Marie Keller Memorial Foundation.

Please send completed registration forms and payment to:

The Emma Marie Keller Memorial Foundation
746 White Road
White, PA 15490

Name: _____________________________________________________________
Street Address: ______________________________________________________
City: _________________________________ State: ______ Zip: ______________
E-mail Address: ______________________________________________________
Phone: ____________________________________________________________

T-Shirt Size:    Child:     Small _____  Medium _____ Large _____
Adult:     Small _____ Medium _____ Large _____ X-Large _____ XX-Large _____

*** Please list the names of each participant and how many t-shirts of each size. Thank you. ***

Registration Fees: Adult: $25    Children $15

Participation Agreement:

I understand that my consent to these provisions is given in consideration of the acceptance of this registration and for being permitted to participate in this event.  I am a voluntary participant in this event and in good physical condition.  I know this event in potentially hazardous and I hereby assume full and complete responsibility for an injury or accident which may occur during my participation in this event, and I hereby release and hold harmless and covenant not to file suit against the Preeclampsia Foundation, The Emma Marie Keller Memorial Foundation, and their local affiliates, and any affiliated individuals, any sponsors, and their agents and employees, and all other associates and entities associated with this event (the releasees) from any loss, liability or claims that I may have arising out of my participation in this event, including personal injury or damage suffered by me or others, whether same caused by falls, contact with participants, conditions of the course, negligence of the releasees or otherwise.

I have read the participation agreement and give my full permission to the Preeclampsia Foundation and The Emma Marie Keller Foundation and their local affiliates and their sponsors to use any photographs, videotapes, or other recording that are made of me during this event.

Signature: __________________________________ Date: __________________
(Participates under 18 need a parent/guardian to sign their registration form)