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Make Checks Payable to: KVRRC

Send Entry Form to:
Kanawha Valley Road Runners Club
19 Riverside Drive
South Charleston, WV 25303

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NAME

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AGE ON MAY 12, 2007                          MALE OR FEMALE

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ADDRESS     
           
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CITY                   STATE                   ZIP CODE

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TELEPHONE NUMBER


CIRCLE SHIRT SIZE (circle one):    Medium       Large       XLarge

WAIVER: (MUST BE SIGNED OR ENTRY WILL NOT BE ACCEPTED)
In consideration of the Poca River 15K Road Race. For myself, my heirs, executors, and administrators, I hereby release any and all runners, the sponsors, or the county or state in which this race is contested. I attest and verify to the best of my knowledge, my physical condition and fitness are adequate for me to safely compete, and no physician or qualified individual has advised me against competing in the Poca River 15K.

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SIGNATURE
(Parent/Guardian MUST sign if runner is under 18 years of age)