Panther Valley Running and Fitness Club

 133 W. Holland St.

Summit Hill, PA 18250

Phone: (570) 645-2170

Email: mogorun@ptd.net

Name:________________________________ Date of Birth:________________

Address:__________________________________________

City:________________________________ State:______  Zip__________

Yrs you have been running:______  Yrs you have been club member_________

Miles a week_______     How many days a week do you run?_____

Cross Training:  What else do you do?______________________________

_____________________________________________________________

Favorite Courses:_______________________________________________

Personal bests:  1 mile_______  2 mile_______  5K_______  10K_______

10 miles__________  Half marathon:__________  Marathon___________

Ideas for the club:_____________________________________________

DUES:  Individual:  $5.00   Student:  $1.00   Family  $7.00  (payable to the Panther Valley Running and Fitness Club).  Send to above address at top of page.