Saturday, September 25, 2010 -- Marlinton, WV
WV Roadkill Possum Trot 5K Run/Walk ENTRY FORM
CONTACT:
-
Nelson Hernandez, Phone: 304-799-6377, E-mail: wvnelson@frontiernet.net
OR Gail Hyer, Phone: 304-799-4636, E-mail: hyer@pocahontascountywv.com
Make check out to: PCCVB // Mail to: Pocahontas County Chamber of Commerce (PCCVB), P.O. Box 275, Marlinton WV 24954
Entry Fee: $12.00 before September 1st, $15.00 thereafter and on race day
Last Name: ___________________________________________________________________
First Name: __________________________________________________________________
Address: _____________________________________________________________________
City: ___________________________________________State: _______ Zip: _________
Phone Number: (___________)___________________________________________________
E-mail Address: ______________________________________________________________
Emergency Contact Name: ___________)__________________________________________
Age: _________ Date of Birth: _____/_____/_____ Gender (circle one): Male Female
Please circle your age division below:
14 & under . . . 15 & 19 . . . 20 & 29 . . . 30 & 39 . . . 40 & 49 . . . 50 & 59 . . . 60 +
Circle T-shirt size: Small . . . Medium . . . Large . . . X Large
WAIVER: I know that running a road race is a potentially hazardous activity. I should not enter and run unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all the risks associated with running in this event but not limited to fall, contact with other participants, the effects of weather, including high heat and/or humidity, traffic and other conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the Pocahontas County Chamber of Commerce and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event. I grant permission in this event to all of the foregoing to use any photographs, motion pictures, recordings or any other record of this event for any legitimate purpose. All forms must be signed. Incomplete or unsigned forms will not be accepted.
Signature ___________________________________________________________________________
Date __________________________________
Signature ___________________________________________________________________________
Date __________________________________
Signature of parent or guardian if entrant is under 18.
Write this phone number down and if you have any questions, just give us a call 304-799-6377.
Have a great time at the Race and famous West Virginia RoadKill Cook-off.