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Saturday, September 15, 2012 -- Fairmont, WV / NASA IV&V Facility in the I-79 Technology Park
CFC 5K Race @ NASA IV&V, Run/Walk/Kids K ENTRY FORM (iPO Event Id#: 14166) -- Return to the Details Page

Register Online for the [ RUN ] . . . [ WALK ] . . . [ KIDS K ]

RACE CONTACT: Eric Sylvania (e-mail) (phone) 304-367-8266

Entry Fee for 5K Run/Walk: Before 08/31 = $20 ... After 08/31= $25 (Kids K Free)

Make checks out to: Combined Federal Campaign and Mail to:

CFC 5K Run/Walk & Kids K Attn: Bree Layton, 100 University Drive, Fairmont, WV 26554

Last Name: ____________________________ First Name: ______________________

Address: ______________________________________________________________

City: ____________________________________ State: _________ Zip: ___________

Phone: ________________________ Email: __________________________________

Emergency Contact: ___________________________ Phone: ____________________

Age: ___ Date of Birth on race day (mm/dd/yy): ____/____/____ Gender: ___Male ___Female

Run___ or Walk___

T-Shirt Size (check one): ___S ___M ___L ___XL ___ XXL

Youth T-Shirt (check one): ___S ___M ___L ___XL

All forms must be signed. Incomplete or unsigned forms will not be accepted.

WAIVER: By checking the box below, you agree, warrant and covenant as follows: In submitting this entry, I, intending to be legally bound for myself, my heirs, executors and administrations, waive, release and forever discharge any and all rights and claims which I may hereafter accrue against the CFC 5K Run/Walk & Kids K, any event sponsors, event volunteers, event staff, and their officers, directors, agents, successors and/or assigns for any injuries suffered by me at this event while traveling to and from the event or while participating in it. I attest and verify that I am physically fit and sufficiently trained for the competition of this event. I understand that I may be photographed and agree to allowing my photo, video, or film likeness to be used for legitimate purpose by the aforementioned parties.



Date _______________________

SIGNATURE of Parent/Guardian if entrant if under the age of 18

Date _______________________