Saturday, September 25, 2010 -- Clarksburg, WV
FBI Jerry Dove Memorial 5K Run/Walk & Kids-K
ENTRY FORM
CONTACT: Lisa Vincent Stout, Phone: 304-625-5807 / 304-625-4970, E-mail: lisavincentstout@hotmail.com
$15 Entry Fee for 5K Run or Walk, $5 for Kids-K
Pre-registration is highly encouraged, shirts/patches are guaranteed only to persons registered on or/before September 7th.
Make checks payable to FBIRA and mail to: FBIRA 5K
FBIRA 5K
1000 Custer Hollow Road
Clarksburg, West Virginia 26306
NAME: _________________________________________________________________________________
ADDRESS: ______________________________________________________________________________
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TELEPHONE: (_________________)____________________________________________
E-MAIL: __________________________________________________________________
DATE OF BIRTH: _______/_______/_________________ // AGE AS OF RACE DATE: ___________________
MALE _____ FEMALE _____ // KIDS-K PARTICIPANT _____
Amount enclosed with application: $________________
T-SHIRT SIZE: SM_____ MED_____ LG_____ XL_____ (Youth sizes will be provided if KIDS-K Participant.)
RELEASE STATEMENT:
In consideration of acceptance of this entry, I waive any and all claims for damages which may result from my participation, or from the participation of the minor that I am signing for in the FBI Jerry Dove Memorial 5K. Any and all claims are waived for myself, heirs, and assigns. The sponsors, their agents or representatives, and/or property owners where the event is being held will assume no obligation for injuries or damages that may be incurred.
______________________________________________________________________________________
Signature of Runner
______________________________________________________________________________________
Signature of Parent or Guardian (if applicant is under 18 years of age)