American Chemical Society
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Younger Chemists Committee = " * 5K Fun Run/1.5 Mile Walk Monday, March 24,2003
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RACE STARTING AREA — ERNEST N. MORIAL CONVENTION CENTER, NEW ORLEANS, LA REGISTER EARLY TO ENSURE ENTRY! Return completed entry form with registration fee: ACS, Meetings Department, L155 16th Street, N.W., Washington, D.C. 20036, Customer Service Inquires: phone 1(800) 650-2512, e-mail
[email protected], or ? ax (202) 872-6128. ENTRY FORM: 3 Dr. QMr. • Ms. • Mrs.
First Name
MI
Last Name
E-Mail Address _ Mailing Address 3ty
State,
Phone
Fax
CHECK ALL THAT APPLY: • Walk
• Run Sex: • Female
• Male
Age race day: • Division I = 35 and under • Division II = 36-49 • Division III = 50 and over
Registration fee: • Regular $20 • Student $10
Those who register prior to February 26,2003, will receive a T-Shirt T-Shirt Sizes:
• Small
•Medium
• Large
• X-Large
• XX-Large
Pick up bib numbers and register on-site at the YCC 5K Fun Run/1.5 Walk Booth in the ACS meeting registration area of the Ernest N. Morial Convention Center on Saturday, March 22 from 3:00-6:00 p.m. and on Sunday, March 23 from 7:30 a.m.-7:00 p.m. Registration will be closed on race day.
PAYMENT METHOD: Paid by: • Check should be made payable (in US dollars only) to ACS. • VISA
• MasterCard
• American Express
• Discover
Credit Card Number_
.Exp. Date.
Credit Card Billing Street Address . _Zip Code Card Holder Name Card Holder Signature.
lounger Chemists Committee 5K Fun Run/1.5 mile Walk hereby understand that upon my entry into the YCC Fun Run/Walk, located in New Orleans, LA, on vlonday, March 24, 2003,1 waive any and all claims for damages that I may have against ACS, sponsors, >r any involved in the production of this race, in regards to any and all injuries suffered by me while runling, walking, traveling to or from, or participating in this event, for myself, my heirs and or assignors. IGNATURE:.
_DATE
. Zip
