Application   Please Print Page and Submit to address shown below   
14th Annual Sam’s Butterfly Run  (5k Run and 1-Mile Fun Walk)
Sam Mizrahi Memorial Fund

When:  1pm Sunday May 17th  2020  (registration at 12:30)
Where:  Northern High School Complex (Check-in near High School Gym Entrance)

  • 5K Run       Adults - $20      Students - $10
  • 1-Mile Fun Walk  - $10
  • T-Shirt  $15
Proceeds will be go to the Sam Mizrahi Memorial fund which will award a scholarship to a Northern Senior.
Please complete form below and mail with check to:   Mizrahi Family, 100 Fairway Dr., Dillsburg Pa, 17019
(checks payable to TFEC-Sam Mizrahi Memorial Fund)
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 I wish to enter Sam’s Butterfly Run and Walk. I am medically fit to run or walk the distance involved,
and will not hold the organizers responsible for any injury or loss to my property or person however
caused, before, during or after the event. 

Name _______________________Run or Walk 

Name _______________________Run or Walk

Name _______________________Run or Walk

Name _______________________Run or Walk

Name _______________________Run or Walk

T-Shirts -  $15      S___     M___     L___     XL___    XXL__

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