Print Registration print Entry FeeAdult (Ages 19 & up): $30 / registration includes t-shirt if post marked by 10/12/2019Child (Ages 18 & under): $20 / registration includes t-shirt if post marked by 10/12/2019Adult (Ages 19 & up): $35 / registration DOES NOT guarantee t-shirt if post marked after 10/12/2019Child (Ages 18 & under): $25 / registration DOES NOT guarantee t-shirt if post marked after 10/12/2019Please note price increase if registration is postmarked on or after 10/12/2019Name First Last PhoneAge0123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100SexMaleFemaleEmail Emergency Contact NamePlease list a person we can contact on your behalf if an emergency or urgent situation arises. First Last Emergency Contact PhonePlease the phone number of your emergency contact person.Team NameParticipate In:4 Mile Run2 Mile WalkT-Shirt Size S M L XL XXL No Shirt Please disregard if registering after Oct 12, 2019. T-shirts will be available as first come - first serve at packet pick up.Youth T-Shirt Size S M L No Shirt Please disregard if registering after Oct 12, 2019. T-shirts will be available as first come - first serve at packet pick up.Add "I Trot In Memory Of" or "In Celebration Sign Of" Sign In Memory of (person has passed) In Celebration of (person is living) Each sign is $10. Please include this cost with your registration amount. You will have the option of writing your message on the sign at packet pick up.Are you a survivor of Pancreatic Cancer?YesNoAdditional Donation $Print and mail with your check to: Theresa Tracy Strive To Survive PO Box 2464 East Peoria, IL 61611 Make checks payable to “Theresa Tracy Strive to Survive” For Questions Contact Orin Naramore: 309-261-2157 In Consideration of the acceptance of my entry, I for myself executor, administrator, and assignees do hereby release and discharge Theresa Tracy Strive To Survive, City of East Peoria, and all other sponsers from all claims or damages,Signature (Parent Signature if under 18 yrs old.) _____________________________________________________________Date Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.