Saturday, April 17, 2010 -- Charleston, WV
Run for a Wish - Melinda Taylor State Farm ENTRY FORM
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Please make checks payable to: Run for a Wish
Mail to: Melinda Taylor State Farm Agency /Attn: Tara Romberger, 101 Pennsylvania Avenue Charleston, WV 25302
Name: _________________________________________________________________
Address: ______________________________________________________________
City: _________________________________________________________________
State: __________ Zip Code: __________________________
Phone: (__________)_______________ E-mail: ____________________________
Age Bracket: 14 & under ____ / 15-20 ____ / 21-30 ____ / 31-40 ____ / 41-50____ / 51-60____ / 60+ ____
Female ____ /or Male ____ // Run ____ or Walk____ //Shirt Size: S ___ M ___ L ___ XL ___
Waiver: For and in consideration of my participation in the Run for a Wish 5k run or 2 mile walk, I, the undersigned, release forever the sponsors, the program, its members, volunteers, co-sponsors, landowners, race organizers, race directors, other participants, the City of Charleston, the County of Kanawha, West Virginia and all those associated with the Run for a Wish run and walk from any claim for harm, injury or loss that occurs to me or my child/ward or anyone on his/her behalf as a result of participation in this event. I therefore attest and verify that I am physically fit and have sufficiently trained for this event and I am aware of the potential dangers.
_______________________________________________________________________
Signature (Parent/Guardian must sign if under 18)