Saturday, July 25, 2009 -- Bartow, WV
Durbin Days Back Road 5K (iPO Event Id#: 12189)

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Please make checks payable and
Mail to: Mike Stennes, PO Box 2, Green Bank, WV 24944

Name ______________________________________ MALE___ FEMALE___

Address ____________________________________________

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Phone # ____________________________________________

Age on July 25, 2009: _____ Date of Birth ____/____/_____

Circle desired T-shirt size (choose one):

Small ... Medium... Large... XL...

Waiver - MUST Sign: I, the undersigned, do hereby and forever release and discharge the sponsors of the DURBIN DAYS BACK ROAD 5K RUN/WALK from any and all claims, courses of action or suits which I or my heirs shall or may have arising from my participation in the said run/walk, held July 25, 2009. I further consent to the use of my photo in connection with publicity for the run/walk.

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Signature of runner/walker OR parent or legal guardian

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Date