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Saturday, April 18, 2009 -- Charleston, WV
Run for a Wish for Make-A-Wish Foundation (iPO Event Id#: 11751)

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Please make checks payable to: Make-A-Wish Foundation

Mail to: Melinda Taylor State Farm Agency /Attn: Tara Romberger, 101 Pennsylvania Avenue Charleston, WV 25302

Name: _________________________________________________________________

Address: ______________________________________________________________

City: _________________________________________________________________

State: __________ Zip Code: __________________________

Phone: (__________)_______________ E-mail: ____________________________

Age Bracket: 14 & under ____ / 15-20 ____ / 21-30 ____ / 31-40 ____ / 41-50____ / 51-60____ / 60+ ____

Female ____ /or Male ____ // Shirt Size: S ___ M ___ L ___ XL ___

Waiver: For and in consideration of my participation in the Run for a Wish 5K run or 2 mile walk, I, the undersigned, release forever the sponsors, the program, its members, volunteers, co-sponsors, landowners, race organizers, race directors, other participants, the City of Charleston, the County of Kanawha, West Virginia and all those associated with the Run for a Wish run and walk from any claim for harm, injury or loss that occurs to me or my child/ward or anyone on his/her behalf as a result of participation in this event. I therefore attest and verify that I am physically fit and have sufficiently trained for this event and I am aware of the potential dangers.

Signature (Parent/Guardian must sign if under 18)