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.