On this page:
       Membership Registration Form
       Bowl-a-thon Pizza Party
          to be post tomorrrow                                                     
         Texas Hold'em Registration Form    to be posted tommorrow

          


Spina Bifida Resource                                           Membership/Registration Invoice 2011
       209 E State Street, Quarryville, PA 17566                                 Read and Print Carefully

 Mailing address

Name  ____________________________________________________________________________________
Business or Organization  ______________________________________county  _____________________
Address____________________________________________________________________
City, state & zip ____________________________________________________________
Home phone  ___________________________________ work phone  ______________________________
email address  ________________________________________________ for  _________________________
email address  ______________________________________for __________________________

 Email options:  Help us save postage and paper.  Check items you would like to receive by email:
           ____ Spina Bifida news             ____ Education issues               ____ Legislative issues      

Chat rooms: 
            
___ SB parents    ___ SB adults   ___SB Occulta      Chat with others across the country
         

Check type of membership (must choose one)
_____ $25 Consumer* - household of an adult with SB   Spouse’s name __________________________________

_____ $25 Family* - household of parent(s) or guardian(s) of those born with SB
_____ $30 Relative - of a person born with SB _______________/_______________________________
                                                                             relationship                              person with SB
_____ $50 Professional or Agency  - works with those born with spina bifida.
      field _________________________________________  title _________________________________
_____ $30 General - friend to the Association
_____$25 I belong to another chapter but would like your newsletter.  Chapter  ___________________________________
____ Consumers or Family members in PA, who cannot afford membership at this time, may check here to request a membership grant.  
Consumer and family information: (list additional persons with their information on separate page)

Person with SB  ________________________________ (male / female) birth date  ______________________
High school graduation year ______________             

2nd Person with SB  ________________________________ (male    female) birth date  _____________________
High school graduation year ______________                  
Do you attend a Spina Bifida Clinic?    yes     no     Which one(s) ____________________________
Mom’s full name ______________________________  Dad’s full name ____________________________________

Lives with (please circle):      parent(s)      spouse      alone    other  ___________________________

Working   _____ hours per week   Not working because  ______________________________________

 

Please list all family members’ employers, as this may help us get grants.  Circle any with matching gift programs. _______________________________________________________________________________________________________

_______________________________________________________________________________________________________

 Qestions or concerns ______________________________________________________________________

________________________________________________________________________________________________________________________

Please make checks payable to Spina Bifida Resource     Membership         ___________________

Thank you for your support!                                          Donation               +   _______________
                                                                                       Tot
al enclosed      $ _________________

                                                                                                                                                                                               


Lancaster Corporate RunIndividual Challenge  *  Kids for Kids Run  


           Spina Bifida    5K    

                                 Run  *  Walk  *  Roll  


Saturday, October 9, 2010

Greenfield Corporate Center, Lancaster PA

 

Benefits  Kids born with Spina Bifida

          SPINA BIFIDA is the # 1 CRIPPLER OF NEWBORNS

 

Current sponsors:  Fulton Bank  *  High Industries  *   Prestige Color

Saturday, October 9, 2010


TIMES:                    Race packet           8:00 – 9:15 am
                                             Kids Race               9:00 am
                                             5K Races                9:30 am
                                             Walk                         9:35 pm   choice of 1.5 mile or 5K course
                                            Awards & Raffle                           after the event

PLACE:    Greenfield Corporate Center, Lancaster, PA

                    Take Route 30 to Greenfield Road, north to William Penn Way, turn right.

COURSE:     Scenic Greenfield Corporate Center, course available by email SBAofPA@aol.com

ENTRY:     Pre-registration discount    $17 person, until 9/25/10, includes a T-shirt.
                           Day of the event   $20 person, T-shirts while they last.
                           Kids Run  $5, until 9/25/10.   Day of the event $10  

The Corporate Cup – awarded to the fastest Corporate Team

Teams will consist of a minimum of three (3) members.  Members must currently work for the company.  Companies may enter as many teams as desired.  
Team members are eligible for individual awards.
Teamscores will be the accumulation of times of the first 3 team members to cross the finish line.


INDIVIDUAL COMPETITION:    
                           
MEN:
  
60 and over,  50-59,  40-49, 30-39, 20-29, 19 and under. 
                            Women:   60 and over,  50-59,  40-49, 30-39, 20-29, 19 and under            

                                     WHEELCHAIR:Individuals using wheelchairs.

AWARDS:  1st, 2nd & 3rd Place in each category
                              Sponsorship Award - one who collects the most sponsorship money  

KIDS FUN RUN:            Age:   5-7       1/4  mile run
                                                        Age:   8-12     1/2  mile run

AWARDS:  Participant Ribbon for all
                             1st, 2nd and 3rd place certificate per group
                             Sponsorship Award - one who collects the most sponsorship money

 
Registration Form

Check one:     _____Run   _____Walk                      _____Roll

Check one:     _____Team     _____Individual   _____Kids Run

 Age on race day   _________                         Circle:   Male    Female

Runner_____________________________________________________

Address _____________________________________________________

City, state, zip  _________________________________________________

Phone   _____________________________________________________

Email  ______________________________________________________

Adult T-shirt size (circle)          S       M       L       XL       XXL    (for Walk, Run or Roll)

Team runners are strongly encouraged to wear matching T-shirts with company and/or team name.  Numbers will be provided by race organizer.

 Company or Team Name: _______________________________________________

 Team captain:  ________________________________________________________ 

Waiver:  I release the Spina Bifida Resource, and any other sponsors or officials involved from any and all damages or injuries incurred or arising from my participation in the SB 5K Corporate Run for Spina Bifida, and other events held on October  9, 2010.

 Runner’s signature _____________________________________________________

Parent’s signature required if under 18 ______________________________________

SPONSORSHIP:  Many levels available; most include free runners!                                                            Call for a sponsorship form for your Company!

CONTACT:            Patricia Fulvio, Executive Director     717-786-9280     or     SBAofPA@aol.com     

 
Pre-registration appreciated.  Thank you.

   Payment:    ____  I will bring $50 or more in sponsorships and Run Free!

                          ____  Runners/Walkers       $17 (until 9/25) or $20        ________________

                           ____  Kids Run                    $5 (until 9/25) or $10           ________________

                         ____  Sponsor a runner w/SB                                             ________________

                         Donation                                                                                ________________

                                                       Total                                                         $_______________

 

CHECKS PAYABLE:  Spina Bifida Run

                                      209 E. State Street, Quarryville, PA  17566

 
Sponsorship form
Sponsor’s Name                       Address                                                                   Donation     Paid

__________________________________________________________________________________________________________
________________________________________________________________________________________________________________

 ________________________________________________________________________________________________________________
__________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
 _________________________________________________________________________________________________________________
 __________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
 _________________________________________________________________________________________________________________
 _________________________________________________________________________________________________________________

 

 Thank you!

 __________________________________

 Spina Bifida Texas Hold'em Poker Tournament  

November 13, 2010  

First hand dealt at 5 pm sharp!   Doors open at 3:30 pm

 
                                           Cash prizes 

 
St Catherine’s Church 955 Robert Fulton Highway, Quarryville, PA

Across from Solanco High School

 Registration form


Name _________________________________________________________

Address _______________________________________________________

_______________________________________________________________

Phone _________________________________________________________

Email __________________________________________________________

                $50.00 Buy-In       Make checks out to:    Spina Bifida Poker 

 
Pre-registration requested to help with set-up and food prep.            You must be 18 or older.

Questions, contact Pat:     717-786-9280    SBAofPA@aol.com

Benefits kids born with Spina Bifida.   Thank you!