Entry Form - 4-H Duck Race & Fun Run/Walkathon
Please print and complete the following form and return it to:
4-H Duck Race, c/o Cooperative Extension, 615 Willow Avenue, Ithaca NY 14850-3555
Duck chance purchase forms will be accepted by mail until April 27, 2012, and in person until
1 p.m. on launch day.
NAME: ______________________________________________________________________
ADDRESS: ___________________________________________________________________
CITY:__________________________________ STATE: _________ ZIP: ________________
PHONE: ________________________________ EMAIL: ______________________________
How did you hear about the Duck Race & Fun Run: ____________________________________
RUBBER DUCK RACE
I'd like chances on ______ ducks at $5 each, or 5/$20 = $__________.
NOTE: Individuals must be 18 years of age or older to purchase duck chances.
FUN RUN/WALKATHON ENTRY
Enter me in the: Fun Run ($10 Advance, $20 day of race) = $__________
Gender: [ ] M [ ] F Age: ______ T-shirt size: ____ (free to 1st 50 entrants)
Additional runners/walkers on this form:
Name: _______________________________________________________________________
Gender: [ ] M [ ] F Age: ______ T-shirt size: ____
Name: _______________________________________________________________________
Gender: [ ] M [ ] F Age: ______ T-shirt size: ____
Please check one:
Program being credited for this sale:
O 4-H Club _______________ O Primitive Pursuits O 4-H Urban Outreach ___________ O RYS _____________
DUCK CHANCE TOTAL: $__________
5K TOTAL: $__________
= TOTAL DUE: $_____________
[ ] I enclose my check for $____________ payable to "CCETC" with "duck race" written in the memo line.
[ ] Please charge this order to my (circle one) VISA / MasterCard #_____________________________
Exp. Date: ______. Your name as it appears on the card:_________________________________
Daytime phone in case we need to call re: this charge: ________________________________
To charge your order by phone, call: (607) 272-2292
