Join Pacesetters of Fox Cities, WI

Print out this form, complete as required and return with payment to the address below: (Please make checks payable to the PaceSetters, Inc.)

PaceSetters, Inc.
PO Box 681
Menasha, WI 54952-0681

Membership Application

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Name:	__________________________________________________________
Address:	__________________________________________________________
City:	_________________________	State:	___________	ZIP:	___________
Phone:	____________________________
E-mail:	____________________________
Birthdate:	_______________ MM/DD/YEAR
Gender:	____ Male ____ Female

Membership status:
Membership Level Desired - please check appropriate item:

____

NEW

____

RENEWAL

Individual Membership

____

1 year $20.00

____

2 year $40.00

____

3 year $60.00

____

4 year $80.00

____

5 year $100.00

____

Lifetime $150.00

Family Membership

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1 year $35.00

____

2 year $70.00

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3 year $105.00

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4 year $14000

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5 year $175.00

Members are asked to assist at least one event per year.
Please indicate your choice below:

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Fun Run/Walk(s) - 2nd Wednesday of each month

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Run for Home 5K & Youth Runs for Fitness - April 11, 2010

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PaceSetters XC Run - August 4, 2010

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Cheesehead 1/2 Marathon & 5K Run/Walk - August 28, 2010

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St. Joseph Food Pantry 5K Run/Walk - October 16, 2010

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Marathon/half marathon training runs (Held weekly May – Sept)

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Community First Fox Cities Marathon - September 17-19, 2010

Upon submission of this application, I agree to assume all risks associated with participation in any activity of the PaceSetters Running Club. I release all sponsors, officers, board members, employees and any person assisting on a voluntary basis from any claims of liability resulting from my participation.

Thank You!

PaceSetters, Inc. PO Box 681 Menasha, WI 54952-0681

PaceSetters, Inc.
PO Box 681
Menasha, WI 54952-0681