Pumpkin Chase Registration with Payment

REGISTER and PAY NOW for
The Great Pumpkin Chase & One Mile Fun Run
October 25, 2008

Please complete one registration for each entry

Name of Runner
Address
City
State
Zip
Sex	Male Female
Age (on 10/25/2008)
Race Day Age Group
Date of birth
Phone (with area code)
Email Address
Shirt Size	M L XL XXL
Race entry for	Self A Minor (under 18)
Which event are you entering?	5K Fun Run/Walk
Name of person completing form
Relationship to runner	Self Parent Guardian
WAIVER: By completing and submitting this form, I certify that I (or the runner, if submitting for a minor) suffer no condition likely to cause injury or illness from participation in this event. I waive and release any and all rights I/the runner may have against the sponsors, their agents, employees, tenants, volunteers, and the city of Harrisburg for damages, injuries or losses I/the runner may suffer as a result of this event.
*Fun Run Winner 2004*
*Payment Information*
Name on credit card
Registration Fee	$20.00 (US funds)
Credit Card Type	No other card types accepted at this time.
Credit Card Number
Expiration Date
Credit Card Billing Address
Credit Card Billing ZIP Code
Credit Card Verification Code	[How do I find my Credit Card Verification Code?]
*Please PRINT A COPY of this page for your records* Please VERIFY* all information before clicking the Submit button.*

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