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