Wellness Warrior Run Registration Form

Wellness Warrior Race

(Run/Walk 5K Benefitting Baby Sarah's Playground
Race Date: Saturday, October 11,2025
Location: Perry County Fairgrounds
Start Time: 9:00 am

Please Note: Each Participant Must Complete a Separate Registration Form and Payment

*This form is for online payments only. If you wish to pay by check or cash, please register and pay at PCH Wellness Center.*
- Name*
  
  First NameLast Name
- Gender*
- Age*
- Email*
  example@example.com
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Adult SmallAdult MediumAdult LargeAdult XLAdult 2XLYouth SmallYouth MediumYouth Large
- Contact Person: *
  
  First NameLast Name
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Relationship*
- - Early Bird: July 21 to Aug 21, 2025, $32 for 5K, $22 for 1-Mile
  - Regular: Aug. 22 to Sept. 26, 2025, $37 for 5K, $27 for 1-Mile
  - Last Minute: Sept. 26, 2025, to Oct. 11, 2025, $42 for 5K, $32 for 1-Mile
  T-shirt not guaranteed for Last Minute Sign up.
  
  Packet Pick up: Friday, October 10, 2025 at Welness Center from 3:00pm- 7:00 pm and Saturday, October 11, 2025 at the Start Line from 8:00 am- 8:45 am
  
  Awards: Presented at Finish Line, following both 5K and 1-Mile
- 5K Run/ Walk Race RegistrationKids 1-Mile Fun Run/ Walk
- YesNo
- By signing this registration form, I hereby agree that I, on behalf of myself and my heirs, agree to hold harmless Pinckneyville Community Hospital, the City of Pinckneyville and all affiliates for my health, safety, injury, disability, or death arising from or resulting from participating in this event. I give permission for all photos and information to be used for any legitimate purposes. I understand that no rain dates or refunds will be given in the event of conflict, illness, personal injury, weather, etc. Shirts and awards will not be mailed.
- Signature*
  
  Powered by Jotform SignClear
- Parent/ Guardian Signature (If participant is below 18 years old)
  
  Powered by Jotform SignClear
- Payment Options
  Please bring Cash or Check to Casey McDonnough at PCH Wellness Center
- My Products*
  Categories:All
  
  All
  
  Early Bird (July 21- August 21)
  
  Regular (August 22- Sept 25)
  
  Last Minute (Sept 26- Oct 11)
  
  prevnext( X )
  
  Early Bird (July 21- August 21)
  
  Kids 1-Mile
  $22.00
  
  
  
  5K
  $32.00
  
  
  
  Regular (August 22- Sept 25)
  
  Kids 1-Mile
  $27.00
  
  
  
  5K
  Enter description
  
  $37.00
  
  
  
  Last Minute (Sept 26- Oct 11)
  
  Kids 1-Mile
  $32.00
  
  
  
  5K
  $42.00
  
  
  
  Total
  
  $0.00
- If you do not have a PayPal account, you can checkout as a "guest" on the PayPal Checkout below.
- Payment Methods
  
  Choose from one of the PayPal options to make your payment.
- Should be Empty:

Wellness Warrior Race