Saturday, May 9, 2009 -- Charleston, WV / End of Doc Bailey Road in Cross Lanes, WV
Poca River 15K Road Race ENTRY FORM (iPO Event Id#: 11720)

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Make Checks Payable, Send To: Poca River Run, 9 33rd Street SE, Charleston, WV 25304

Fee $12.00, Race Day $15.00

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NAME

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AGE ON MAY 9, 2009                          SEX // M or F

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ADDRESS     
           
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CITY                                               STATE            ZIP CODE

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TELEPHONE NUMBER

CIRCLE SHIRT SIZE (circle one):    Small       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.

This also is a signed waiver of liability that releases the race organizers, volunteers, officials and USATF from claims for damages.

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