Sunday, January 10, 2010 -- Charleston, WV / Kanawha City Community Center
Winter Series #2 - Run & Walk (iPO Event Id#: 12364)

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Check Payable and Mail To

Charleston Parks & Recreation, Winter Series, 200 Baker Lane, Charleston, WV 25302

Advanced Registration (3 Events) - $35, must be received by December 1, 2009.
$15 for 1 event after Dec. 1 and on Race Day.

Name: _________________________________________________________________________

Address: ______________________________________________________________________

City/State/Zip: _______________________________________________________________

Phone: (_____________) __________________________________

E-Mail: _________________________________________________

Male: _______ or Female: ________ // Run: ________ or Walk: ________

Birth Date:______ / ________/ ______________

Circle One: 14 & under, 15—19, 20—29, 30—39, 40—49, 50—59, 60 – 69, 70 & Over, Wheelchair

Sweat Shirt Size (Check One): Youth L___ or Adult: S___ M___ L___ XL___ XXL___

CHECK _____ CASH______ City ID #_________

Please Check ALL That Apply

• Sunday, December 13, 2009
  _____ WALK: 3,000 M (1.8mi) or _____ RUN: 5,000 M (3.1mi)

• Sunday, January 10, 2010
  _____ WALK: 4,000 M (2.4mi) or _____ RUN: 8,000 M (4.9mi)

• Sunday, February 14, 2010
  _____ WALK: 5,000 M (3.1mi) or _____ RUN: 10,000 M (6.2mi)

  You can register for ALL 3 events with this form. (1,000 meters = .62 miles)

Waiver: I, the undersigned, waive and release myself, my heirs, executors, and administrators, any and all rights and claims for damages, demands, and any other actions whatsoever, which I may have against all participating sponsors and supporters and The City of Charleston, arising out of my participation in this event, including and all injuries, including death suffered me as a result of my participation in this event. I consider myself adequately trained for the completion of this event. Should I suffer an injury or illness, I authorize officials of this event to use their discretion to have me medically treated and transported to a medical facility. I also authorize the sponsors to use any photographs or video taken of me to be used in any promotional materials.

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Signature

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Date

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Parent / Guardian Signature Required Under 18 years of Age

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Date