Saturday, August 7, 2010 -- Clarksburg, WV
Blackberry Festival 5K Race ENTRY FORM
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CONTACT: J.B. Forinash, Phone: 304-622-5822, E-mail: affiliatedpt@hotmail.com
OR Susie Sanders, E-mail: Susie.Saunders@steptoe-johnson.com
Make check payable to and mail checks and application to:
West Virginia Blackberry Festival 5K
c/o P.O. Box 2190
Clarksburg, WV 26302-2190
PLEASE PRINT INFO CLEARLY
Name: _______________________________________________________________________________
Address:_____________________________________________________________________________
Phone: (___________) _________________________________________________
E-mail _______________________________________________________________
Age on Race Day: __________ // Gender: Male_____ Female_____
Shirt Size: S____ M______ L______ XL ___
Waiver: In consideration of acceptance of this entry to the West Virginia Blackberry Festival 5K Run, I waive all claims for myself, my heirs and assigns against the race sponsors, promoters, or officials due to injury or illness which may result from my participation. I attest and verify that I have full knowledge of the risk involved in these events. I am physically fit, and sufficiently trained to participate. I have read the above statement, I understand it, and my signature confirms its full acceptance.
Signature____________________________________________________________________________
Date_______________________________
_____________________________________________________________________________________
Parent/Guardian if under 18 years
Date_______________________________