Saturday, October 27, 2007 -- Charleston, WV / Kanawha State Forest
Great Pumpkin Race
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Make checks payable to: CAMC Foundation
Mail to: Debora Mattingly, PT, 826 Cedar Rd., Charleston, WV 25314
Age (as of 10/27/07)______ Sex M___ F____
Name_______________________________________________________________
Address_____________________________________________________________
Phone (H)__________________________ (W)______________________________
Email__________________________________ CAMC Employee yes___ no___
Mark One Event: 5K run____ Wheelchair Division ___ 1 or 3-mile walk___
Mark One T-shirt size: Youth____ M____ Adult: S____ M____ L____ XL____
In consideration of the acceptance of this entry, I will waive all rights and claims for damage that I may have against Charleston Area Medical Center Physical Therapy Departments or their representatives and assignees. I attest that I am physically fit and have trained for this event.
___________________________________________________________
Signature of Participant
____________________________________________________________
Parent/ Guardian Signature (if under 18 years)