Saturday, August 1, 2009 -- Charleston, WV / Coonskin Park Amphitheatre
Childrens Therapy Clinic's Make A Miracle 5K Walk/Run, 10K Run (iPO Event Id#: 12170)

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Fee: $15.00 if postmarked by July 15th; $20 thereafter
All proceeds provide therapy for special needs children who are economically disadvantaged

Mail fee & entry form to:

Children's Therapy Clinic, 113 Lakeview Drive, Charleston, WV 25313

Name___________________________________________________________________
(Please print)

Gender: Male___ OR Female____ // Age on day of Race________

Address_________________________________________________________________

Phone (____________)______________________________

E-mail____________________________________________

Emergency Contact _______________________________________________________
(Name and relation)

Emergency Contact Phone (____________)______________________________

I am registering for (check only one): 5K walk_____ // 5K run____ // 10K run_____

Waiver and Release of Liability Statement ---- Please carefully read the following Waiver & Release of Liability Statement, then sign your signature. Minors under the age of 18 must have signature of their legal guardian for participation in this event.

In return for permission by the Children's Therapy Clinic to participate in the 5K walk or run, or the 10K run, I release the Children’s Therapy Clinic, Inc. it's members, volunteers, sponsor, donors, and any other participant from any claim for injury or loss that occurs to me, my child, my ward, or anyone else on whose behalf I am representing by my signature. In addition, I attest and verify that I am or the participant for whom I am signing is physically fit and have/has sufficiently trained for this event. I give permission to CTC to use any photo, video footage, etc that is taken during this event for use in future promotional materials.

Signature_______________________________________________ Date____________________

T-shirt size (check one): Small___ // Medium___ // Large___ // XL___ // XXL___

(All adult sizes), T-shirts guaranteed by July 15th registration.