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Saturday, August 3, 2002 -- Benwood, WV
Debbie Green Memorial
5K Run/Walk for Leukemia
(iPO Event Id#: 4757)
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Name _________________________________ Age ________
(on 8/3/02)
Address ___________________________________________
City ____________________State _______ Zip ________
Phone Number (________) ___________________________
Please check the appropriate
Shirt Size: __Med __Large __XLarge __XXLarge
__Male __Female __Master __Grandmaster
__Runner __Walker
For in and consideration of permission to participate in this race, I
for myself, my executors, my heirs, administrative and assigns, waive
and release all rights and claims I have against the sponsors, any
financial participant, and their agents, for any injuries incurred by
me during or in connection with this run. I also agree to return the
timing chip or be assesed a $35.00 fee for the unreturned chip.
Signature ________________________ Date ___________
(parent’s signature if under 18)
Make check payable to: Debbie Green Memorial
Mail entry to: Ronnie Green, Race Director, 506 McMechen Street, Benwood, WV 26031
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