Saturday, August 8, 2009 -- Saint Albans, WV / St. Albans Fire and Police Station
Thomas Memorial Hospital's Road Cruise 5K Run & Walk
ENTRY FORM (iPO Event Id#: 12267)
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Complete entire form, sign and date releases and mail along with check
(payable to Thomas Memorial Hospital Fitness Event) to:

Thomas Marketing and P.R. Department, 4605 MacCorkle Ave., SW , South Charleston, WV 25309

Entry Fee(s) The entry fee for the 5K Walk/Run is $15 prior to August 8th and $20 the day of the race.

• The fee for the family pet is $5 each (limited to dogs on a leash)
• Children under 10 years of age are free
• Funds will be donated to the Thomas Memorial Hospital Foundation Community Education Programs and Santa's Elves.

Name:___________________________________________________________

Address:________________________________________________________

City, State and Zip:____________________________________________

Phone:(____________)____________________________Age 8/8/09______

Male_____ Female____ / T-Shirt Size: S____ M____ L____ XL____

Check the race you are entering: 5k Run_____ 5k Walk_____

Please check all that apply:

• ___ Thomas Memorial Hospital employee
• ___ Saint Francis Hospital employee
• ___ Thor & Athena Division (Male 185 lbs. and over, Female 140 lbs. and over)
• ___ Hot Wheels Division
• ___ Thomas Joint Connection Graduate

• ___ Corporate Team Division (Corporate Team Division requires 3 members and a $50 registration fee. // Team Name:____________________________________________________

• Thomas or Saint Francis departmental team // Team Name:______________________________________________________________________________

  Team Name__________________________________________________________________________

  Are you a member of a Thomas Departmental Team? Yes____ or No______

  Team Name__________________________________________________________________________

  Are you entering a family pet(s)? If yes, list their names(s):__________________________________________________________________________

RELEASE OF RESPONSIBILITY: In consideration of your accepting this entry, I, the undersigned, intending to be legally bound hereby, for myself, my heirs, executors and administrators waive and release any and all rights and claims for damages I may have against Thomas Memorial Hospital, and any other individuals and organizations assisting with the Run and Walk, for any and all injuries suffered by me and/or my family dog in said event. I verify that I am physically fit and have sufficiently trained for the completion of this event. ___________________________________________________________________________________
Signature (Parent to sign if under 18)

MEDIA RELEASE: I give permission for personal images (photos and/or news video) to be taken by agents of Thomas Memorial Hospital and /or new media organizations. I understand and authorize the images may be used for Thomas Memorial Hospital internal publications (newsletter & web site).

___________________________________________________________________________________
Signature (Parent to sign if under 18)