Sunday, March 22, 2009 -- Morgantown, WV / Hazel Ruby-McQuain Park, 1125 University Ave. Morgantown, WV 26505
The MountainEAR 5K ENTRY FORM (iPO Event Id#: 11917)

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Entry Fees: $15 pre-registered by March 18th, or $20 thereafter.

Please make checks payable to: WVU Student Academy of Audiology

Mail to: The Student Academy of Audiology (SAA), P.O. Box 6122, Morgantown, WV 26505

PLEASE PRINT - (APPLICATION MUST BE SIGNED)

NAME:_______________________________________________________________________________

ADDRESS:____________________________________________________________________________

CITY:___________________________________________________STATE:______ZIP:____________

PHONE: (____________)___________________________________

AGE ON 3/22/09:______ MALE:______ FEMALE:_______ // Date of Birth:________________

T-SHIRT SIZE: ADULT: S__ M__ L__ XL__ XXL ____ // CHILD: S__ M__ L__

Waiver of Liability: In consideration of your acceptance of my application for entrance in The MountainEAR 5K , I, for myself and anyone entitled to act on my behalf, waive and release the WVU Student Academy of Audiology, all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my or my child's participation in this event.

___________________________________________________________________________________
Participant's Signature (Parent or Guardian signature if under 18 years old)