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Submitted by David Shaver on Tue, 2009-08-18 05:54

Name____________________________________________________

(Check one) Male____ (or) Female_____ (or) Family______

Address___________________________________________________

City/St/ZIP________________________________________________

E-mail address______________________________________________

Phone (______) ______-_________

Date of Membership_______/_______/___________

Mail with check for $10 Online $15.00 for direct mail to:
Julie Shaver
Galesburg Road Runners Club Secretary
Post Office Box 594
Galesburg, Illinois 61402-0594

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