Football Stadium  8940 Union Centre Blvd., West Chester, OH

Come join your family, friends and neighbors for the 3rd Annual Safe Haven Farms 5K Run/Walk. Men, women and children are invited to share in the excitement as we come together to raise awareness and support for Safe Haven Farms. The “flat and fast” race route begins at the Lakota West Football Stadium and runs NW along Union Centre Blvd. toward Mulhauser Barn then loops back to finish at the stadium.  Safe Haven Farms, a non-profit organization,opened for business on May 19, 2010, providing the new residents on the autismspectrum with a variety of meaningful living, working, learning and leisureactivities in a safe and accepting farm environment.

Awards:  First male and female runners, plus top run finisher in each age and gender division

Runner Divisions:  Male and Female: 14 & under   15-19   
20-29   30-39    40-49  
50-59   60 and over

Registration:  You can register by mail or online with a credit card.

Mail: Mail a form for each participant and enclose a check:  $25 for each adult; $10 for kids 14 and under. See address below.

Online: Register online at www.getmeregistered.com  Pay by credit card: $27.54 for each adult; $11.70 for kids 14 and under (includes processing fee).

Kids 5 & under: Fun Run, no registration required and no fee. (Takes place after the 5K; no tee shirt)

Registrations
completed by September 4 will receive a tee-shirt. You can register after that date but a tee-shirt is not included as part of the registration.

Pick up pre-registered
materials at the Mojo Running Store on Saturday, Sept. 17 between 10:00 am and 2:00.

Walk-up registration on race day begins at 7:30 am at the stadium. Cost $30 for adults and $10 for kids 14 and under.

Make checks payable to SAFE HAVEN FARMS INC.

Send mail in registration to: Mojo Running Store

                                                                            9318 Union Centre Blvd.

                                                                            West Chester, Ohio 45069

Questions or concerns please contact Don O’Brien - 513-779-9964. dgobrien@fuse.net

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Official
Mail-in Registration Form

First Name____________________                       Last Name_______________________

Address___________________________________________________________________

Age on race day:______________ Sex: (circle one):   M         F 

Race Category (circle one): 5k run 5k walk

Telephone #:                                                                              
 Email address:

T-shirt size (choose
one):    S        M             L           XL

WAIVER: In consideration of the acceptance of my entry, I hereby waive on behalf of myself, my heirs, executors and assigns, any and all claim of any nature arising from or due to my participation in the Safe Haven Farms 5k Run/Walk.  I also hereby release Lakota Schools, all sponsors, workers, officials and volunteers from any and all claims arising from or due to my participation in this event.  I agree to follow all rules of participation and acknowledge that the race committee may refuse or return my entry at its discretion.  I understand the risks for such a run or walk, and have trained and prepared adequately in preparation for the event.  I HAVE NOTED ANY MEDICAL CONDITION on this entry form.  I permit the use of my name and likeness while participating in this event for publicity, for no additional consideration.  I also understand that entry fees are non-refundable.

Signature___________________________________________________________       ______________________                                                                                                                                                                   
Date

Parent
Signature, if under 18: __________________________________________              _______________________                                                                                                                                                       Date