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Print out this form, complete as required and return with payment to the address below: (Please make checks payable to the Pacesetters, Inc.)
PaceSetters, Inc.
PO Box 681
Menasha, WI 54952-0681
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Membership Application
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| Name: |
__________________________________________________________
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| Address: |
__________________________________________________________
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| City: |
_________________________ |
State:
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___________ |
ZIP:
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___________
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| Phone: |
____________________________ |
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| E-mail: |
____________________________ |
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Birthdate: |
_____________ MM/DD/YYYY |
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Gender: |
____ Male ____ Female |
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Membership status:
Membership Level Desired - please check appropriate item:
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NEW |
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RENEWAL |
| Individual
Membership |
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1 year
$20.00 |
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2 year
$40.00 |
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3 year
$60.00 |
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4 year
$80.00 |
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5 year
$100.00 |
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Lifetime
$150.00 |
| Family Membership |
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1 year
$35.00 |
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2 year
$70.00 |
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3 year
$105.00 |
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4 year
$140.00 |
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5 year
$175.00 |
Members are asked to assist at least one event per year.
Please indicate your choice below:
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Fun
Run/Walk(s) - 2nd Wednesday of each Month |
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Run for Home 5K & Youth Runs for
Fitness -
April 11, 2010 |
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PaceSetters
XC Run - August 4, 2010 |
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Cheesehead 1/2 Marathon & 5K Run/Walk
- August 28, 2010 |
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St. Joseph Food Pantry 5K Run/Walk
- October 16, 2010 |
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Marathon/half marathon training runs (Held weekly May
–
Sept) |
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Community First Fox Cities Marathon
- September 17-19, 2010 |
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Upon submission of this application, I agree
to assume all risks associated with
participation in any activity of the
PaceSetters Running Club. I release all
sponsors, officers, board members, employees
and any person assisting on a voluntary basis
from any claims of liability resulting from my
participation.
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Thank You!
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