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Saturday, November 10, 2012 -- Fairmont, WV
Veterans Day 10k Run/2 Mile Walk ENTRY FORM (iPO Event Id#: 14322)

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RACE CONTACT: Tina Shaw, Marion County Chamber of Commerce, 304-363-0442 or email:

Please send the entry form and payment to: Marion County Chamber of Commerce 110 Adams Street, Fairmont, WV 26554

Last Name: _________________________________________ First Name: _________________________

Address: _________________________________________________________________________________

City: __________________________________________________ State: _________ Zip: ___________

Phone: ____________________________ Email: _______________________________________________

Emergency Contact: ______________________________ Phone: _________________________________

Age: ______ On (Nov 10 2012) Gender: __Male __Female

T-Shirt Size (check one): ___Small ___Medium ___Large ___XL
(The first 150 registrants are guaranteed a t-shirt) 

Please Check all that Apply: (No Refunds)

____ 10K Run  $25 ($30 after Nov.1)

____ Veteran/Active Duty FREE RUN (Branch of Service_______________________________)

____ 2 Mile Walk  $10 ($15 after Nov. 1)

____ Veteran/Active Duty FREE WALK (Branch of Service________________________________) 

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

DISCLAIMER: I hereby for myself, my executors, and my administrators waive any and all rights and claims I may have against the Marion County Chamber of Commerce or any other agency associated with this event, sponsors of this event, or suppliers for injury or damages suffered by me and which may arise out of or any way be connected with this event. I understand that my participation is voluntary and I recognize that there are risks and hazards inherent in my participation to myself and to others, and I knowingly assume all responsibility and risk involved in this event.


Date _______________________

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

Date _______________________