Spina Bifida Resource
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 + _______________
Total enclosed $ _________________
Lancaster Corporate Run * Individual 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 [email protected]
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 SBAof[email protected]
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 [email protected]
Benefits kids born with Spina Bifida. Thank you!
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 + _______________
Total enclosed $ _________________
Lancaster Corporate Run * Individual 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 [email protected]
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 SBAof[email protected]
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 [email protected]
Benefits kids born with Spina Bifida. Thank you!
