Cost:
Register prior to the Early Bird Cut-off (2/5) for $25
After 2/5 - $30
Day of Event Registration - $35
Youth (ages 5-12) $15
Leprechaun Lep - $10
Please note: Required fields are highlighted in yellow.
First Name:
Last Name:
Date of Birth:
Age on RaceDay (Mar 10, 2012):
Sex: Male Female
Address:
City:
State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip:
Home Phone:
Email:
Shirt Size:
Race:
Team: Not on a Team3 little HalosA Kid AgainAdvanced Drainage System Inc. to Benefit One Way Farm Childrens HomeArts Council of West Chester & LibertyAshley's AngelsBackpacks For Pine RidgeBeckett Ridge ChiropracticBoys and Girls Club Steering CommitteeChi Omega Alumnae of Greater CincinnatiCincinnati Center for AutismCincinnati EyeCare Team for Vision USACompanions on a Journey Grief Support Cystic Fibrosis Foundation E Technologies GroupFreedom Parent CouncilGirl Scout Troop 31499Girl Scout Troop 48088GIVE HOPE Pancreatic Cancer Research & AwarenessHolden On! to benefit the St. Baldrick's FoundationHopewell Girls on the GoJ. Kyle Braid Leadership FoundationJUNIOR ACHIEVEMENT of Butler CountyKyle Babcock Scholarship FundLakota East Upbeat ClubLakota West After PromLakota West High School National Honor SocietyLiberty Early Childhood SchoolLiberty Township Charitable FundMetroParks of Butler CountyMiddletown Public Library SystemMojo Running/Parkinson'sMother Teresa Catholic Elementary SchoolNCH Jr./Sr. High SchoolPaige's Princess FoundationPARACHUTE: Butler County CASAPets Helping PeopleReach Out Lakota, Inc.Roy H. Yelton Scholarship FundShawnee Early Childhood PTASojourner Recovery ServicesSt. Michael School SharonvilleSt. Susanna PTOTeam Tatas-Susan G KomenThe Angel FundThe Center For Respite CareThe Dragonfly FoundationThe Overtones, Inc.University Of Cincinnati College of Medicine to benefit the St. Baldrick's FoundationUrsuline AcademyWest Chester TownshipWoodland ElementaryYoung Life Lakota Zach Smith Memorial Fund
Emergency Contact:
Emergency Phone:
Relevent Medical Conditions:
I understand and agree that there is a $15 replacement fee for lost or unreturned timing chips.