Prairie
100 Registration Form
Print this form, fill it
out, and mail with a check for the proper amount to:
Lincoln Area YMCA
319 W. Kickapoo St.
Lincoln, IL 62656
Name:_____________________________________________________________ Address:___________________________________________________________ City:_______________________________
State:____________ Zip:___________ Shirt
Size:
M
L
XL
q Individual
Registration
q Family Registration
Names of family
members: (Immediate family only, please.)
Name
Shirt Size
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
In
registering for the Prairie 100, I hereby release and waive all
claims against the Lincoln Area YMCA, Odd Fellows Grand Lodge, and
Century Dental Center, their officers and members, successors and
assignees, for damages resulting in injury either to myself or to my
equipment during the above event, or to any member of my immediate
family or to their equipment. Signature:__________________________________________
(Must be signature of primary registrant above.) Enclosed
is my check, payable to the Lincoln Area YMCA, for:
q $17, individual before August
17
q $20, individual after August 17
q $40, family before August 17
q $50, family after
August 17 For
more information, please call Sarah at (217) 435-3915
or e-mail at ymca2@ccaonline.com
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