Information

Name: ______________________________________
Address: ______________________________________
______________________________________
Home Telephone: ______________________________________
Work Telephone: ______________________________________
E-Mail Address: ______________________________________
Date of Birth: ______________________________________
Age at 1st Marathon: ______________________________________
Number of Marathons: ______________________________________
Number of Ultra's: ______________________________________
Total Marathons and Ultra's: ______________________________________
Please List 10 Marathons Run (Date/Finish/Time/State)
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
5. ________________________________________________________________________
6. ________________________________________________________________________
7. ________________________________________________________________________
8. ________________________________________________________________________
9. ________________________________________________________________________
10. ________________________________________________________________________
(Attach Favorite Photo) + $10 Membership Fee

Jerry Schaver
1124 16th Street Ct.
Silvis, IL 61282