Application Sams Butterfly Run

Sam's Butterfly Run

To benefit the Sam Mizrahi Memorial Fund

Application
Please Print Page and Submit to address shown below

5^th Annual Sam’s Butterfly Run

Sam's Mariposa Carrera (Sam’s Sister will participate from Spain)

(5k Run and 1-Mile Fun Walk)

Sam Mizrahi Memorial Fund

When: 1pm Sunday May 22^nd2011

Where: Northern High School Complex

(Check-in near High School Gym Entrance)

5K Run

Adults - $20

Students - $10

1-Mile Fun Walk - $10

Tye-Dye Race 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

T-Shirts - $15

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M _____

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