1st Annual
Stomp Out MPD* 5K RUN/WALK
And One Mile Fun Run for Kids
September 19, 2009
City Park Siloam Springs, Ar
Organized by: The Lewis Family
Race Time: 9:00a
Cost: $15.00 per person, $10.00 per child 5-10, Register by September 5th
Open Registration: 8:00 – 8:45am
Race Day Registration: $25.00
Awards for Male Best, Female Best for 5k, and 10 Age groups
Kids Fun Run is non timed, non-competitive event
First 100 entrants receive a gift bag and T-shirt, the day of the race.
Questions? Email Joella.lewis79@gmail.com or Phone 479-238-4090
All proceeds benefit:
Peg S Lewis Medical Fund
Stomp Out MPD 5K Run/Walk Registration
Name (last) ____________________ (first) __________________________
Address: ________________________________________________________
City: ___________________________ State: ________ Zip Code__________
Sex: _____M_____F Age: (as of September 19, 2009) _________________
Phone: ______________________ E-mail______________________________
Size: (circle one) Small Medium Large X-Large XX-Large
____ CHECK ENCLOSED payable to Peg S Lewis Medical Fund
Mail completed form and check to:
Joella Lewis 722 S College, Siloam Springs, AR 72761
Waiver: In consideration of acceptance of this entry, I for myself, my heirs, devises, executors, administrators and assigns hereby waive, release and discharge any and all claims against the Race organizers, sponsoring or conducting this event, or their employees, representatives, or successors, and ArkansasRunner.com for any and all damages or injuries I may suffer. If I should suffer such injury or illness, I authorize the officials of the Race to use their discretion to have me transported to a medical facility and I take full responsibility for this action. I hereby grant permission for the use of my name and picture in any broadcast, brochure or account of this event. By signing this form, I agree to this statement.
__________________________ ________________________
Signature (Parent Signature if under 18) Date
MPD is MyeloProliferative Dysplasia, a rare form of cancer that turns your bone marrow into a fibrotic material much like cement. It also causes more work on your spleen and liver.
