Saturday, August 23, 2008 -- Saint Albans, WV / St. Albans
Homeland Security 5K ENTRY FORM
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Fee: $12.00 (postmarked by Wednesday August 15, 2008), $15 after Aug. 15
Please make check payable and mail to:
35th CST Family Readiness Group, 5305 Monta Vista Drive, Cross Lanes, WV 25313
Name:__________________________________________________________
Address:_______________________________________________________
________________________________________________________________
Phone:(__________________)_______________________________________
T-shirt size: _____Small ____Medium _____Large _____X Large ___ X X Large
Age:__________ Gender:______ 5K Run_________ OR 3K Walk___________
Heavy Weight Division: Yes / No (males 200+ lbs. / females 160+ lbs.)
Member of the Military: Yes / No
Please chose category you wish to participate in:
(only one category per participant) Age: ________ Heavyweight: ___________ Military: ____________
Waiver must be signed or entry will not be accepted:
In consideration of my acceptance as a participant in the Homeland Security 5K Run / 3K Walk, I the undersigned, intending to be legally bound, hereby for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages I may have against any other individuals, entities or organizations assisting with the 5K Run / 3K Walk, and for any and all injuries suffered by me in this event. 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 Homeland Security 5K Run / 3K Walk.
Signature: ____________________________________________________________
Date: ______________________
(parent or guardian must sign if runner is under age 18 years of age)