1. 2nd Annual Drumstick Derby
2011 Registration Form
Blue Water Area Rescue Mission
Participant Information: 1920 24th Street
Name___________________________________________ Port Huron, MI 48060
Address__________________________________________ Phone: 810-956-0768
City______________________ St______ Zip____________
Phone ( )______________ D.O.B. ____/____/____
Email____________________________________________ 2nd Annual Drumstick Derby
Gender: M F Shirt Size: M L XL XXL (Kids M)
Enter Me In: 5K Walk/Race
 B-WARM Corporate Challenge—Corporation name
_________________________________________
Also Enter me in the:
November 24, 2011
 4 Person Team-Team Name __________________
 Children’s Gobble Wobble Ages 3-6
 Children’s Gobble Wobble Ages 7-10 About the Event
 Individual Participant
This event will help raise funds needed for Blue Water Area
Entry Fee and Payment: Rescue Mission to effectively help the homeless of St. Clair
$25 per person through November 23, 2011 County.
$30 per person on day of event
$10 Children 10 and under
•All registered 5K participants by 11/8/2011 will Start & Finish
receive an official BWARM Lifesaver T-Shirt.
•First 500 registered participants will receive a Drumstick Derby will start and finish at Pine Grove Park in
Hits Sports Pack. Port Huron.
•Collect $75 or more in sponsors and your
entry fee is waived.
Register online at Active.com –or- Your Check or Race Timing
Money Order along with this registration form can be
mailed to or for cash payments, just stop by the mission Timing will be done for each runner
at:
Blue Water Area Rescue Mission
Registration
1920 24th Street
Port Huron, MI 48060
(810) 956-0768 Registration can be completed online at active.com, by mail
or in person. Your Check or Money Order along with the
WAIVER: By indicating your acceptance, you understand, registration form can be mailed or personally delivered to :
agree, warrant and covenant as follows:
I know that running in a road race is a potential hazardous activity. I
assume all risks involved in this event and do not hold the race commit- Blue Water Area Rescue Mission
tee, its volunteers or event sponsors liable for any such risk involved in Be a Life Saver and
1920 24th Street
the said event. Further more, I grant permission for the use of photo- Register Now at Ac-
graphs, motion pictures or records of this event for legitimate purposes. Port Huron, MI 48060
(810) 956-0768
Signature:
_______________________________________
Parent or Guardian’s signature required if under 18