Saturday, August 8, 2009 -- Fairmont, WV / 107 Jefferson Street
The First Annual Union Mission 5K ENTRY FORM
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Make Checks Payable to: West Virginia Rescue Ministries
Mail Payment and Application to: WVRM / Attn: 5K Race, 107 Jefferson Street, Fairmont, WV 26554
Entry Fees:
- $13 per runner if payment is received on or before August 1, 2009
- $15 per runner after August 1, 2009
Name: _______________________________________________________________________
Address: ____________________________________________________________________
City/State/Zip: _______________________________________________________________
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Male: _______ or Female: ________
Age on 8-8-2009: _____________ Date of birth: ________________
T Shirt Size: (Circle one only) Adult XL.. | Adult L.. | Adult M.. | Adult S
RELEASE: In consideration of acceptance of this entry, I waive any and all claims for damages that may result from my participation in this race. Any and all claims are waived for myself, heirs, and assigns. The sponsors and their agents or representatives will assume no obligation for injuries or damages that I may incur.
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Signature of Runner
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Date
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Signature of Parent or Guardian
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Date