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Welcome to the City of Roxboro, NC, Action Line

Today is Saturday, November 21, 2009.

MAYO PARK 5K RACE IN THE PARK ENTRY FORM

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2009 Mayo Park Fall Festival

5K Race in the Park Entry Form

Saturday October 10, 2009

Mayo Park Roxboro, NC

All runners must sign waiver form prior to participation in this event.

* Information is required.

Contact Information

* First Name:
* Last Name:
Business Name:
Email:
* Daytime Phone:	() –
Fax:	() –
* Address:
* City:
* State:
* ZIP:

* Age on October 10, 2009

* Date of Birth

Home Telephone

Male

Female

* T Shirt Size

Small

Medium

Large

Extra Large

XXL

* 5K Run or Walk

5K Walk

5K Run

* Emergency Contact Information: Name

* Relationship

* Telephone Number for Emergency Contact

* Registration Fee - Additional $3.00 conveniience fee for credit card payments - Mastercard or VISA only

* Raffle Tickets $500 Gift Certificate Dicks Sporting Good Tickets are $1 each or Book of 6 for $5 Raffle tickets may be purchased at the event.

* Optional Lunch Tickets for Runners, Family & Friends. Not included in registration fee.

* Total (Make Checks Payable to Person County - Mayo Park)

Credit Card Information

Credit Card Number

Expiration Date Month

Expiration Date Year

CVS Number (3 or 4 Digit Number on Back of Credit Card)

Total Amount Charged to Credit Card

Check here to have email confirmation of this request sent.

* Information is required.

Mail Completed Form To:

Mayo Park Trail Race

Person County Recreation Arts & Parks Department

425 Long Avenue

Roxboro, NC 27573

Contact Information:

John Hill

Telephone: (336) 597-7806 Mayo Park

Telephone: (336) 597-1755 Office

E-mail: johnhill@personcounty.net

Visit our websites at:

http://mayo.personcounty.net or http://recreation.personcounty.net

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