Richard Dellaca Pump & Run
Registration
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Richard Dellaca Pump and Run Registration Form Checks payable: Richard Dellaca Memorial Fund Mail to: Nicole Rowe 4139 Easton Blvd Des Moines Iowa 50317 Cost: $15.00 ages 18 and up $20.00 day of the event -$10.00 ages 17 and under $15.00 the day of the event
Name: _______________________ Address: _____________________
City: _________________ State: _____ Zip: _______ Email Add: __________
Events (circle one)
- 3 Mile Pump & Run
- 1 Mile Pump & Run
- 3Mile Run/Walk Only
- 1 Mile Run/Walk Only
Age Group (circle one)
- 14 and under
- 15-18
- 19-24
- 25-29
- 30-34
- 35-39
- 40-44
- 45-49
- 50-54
- 55-59
- 60+
Gender (circle one)
T-Shirt Size (circle one)
In consideration of your acceptance of this entry, I hereby, my heirs, executors, administrators, waive any rights and claims for damages I may have against Saydel High School, Dellaca Family and any or all individuals or groups associated with this events, their agents, representatives, successors and assigns for any and all injuries suffered by me in said event. And I am physically fit and sufficiently trained to participate in this event.
Signature:_______________________________ Date: _____________________ Parent signature if under 18: ________________________________________
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