Sunday, November 22, 2009 -- Rowlesburg, WV / Starts at Rowlesburg Park
K of C Rowlesburg 10K Run / 5K Run and Walk
ENTRY FORM (iPO Event Id#: 12337)

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Entry Fee: Fee is $15.00 if postmarked by November 14th and $20.00 thereafter

Make checks to: Make checks to CPMS Cross Country

Mail To: David G. Pauly, 603 Borgman Road, Kingwood, WV 26537

Name: ___________________________________________________________ Male: ___ Female____

Address: ________________________________________________ Birth Date: ____/____/______

City: ______________________________________________State: ________Zip: ______________

Phone: ( )_________________________ Shirt Size: S M L XL Age:______

Choose Race: 10K____ -- OR -- 5K_____

In consideration of your acceptance of my application for entrance in the Rowlesburg 5 & 10-K River Run I, for myself and everyone entitled to act on my behalf, waive and release the Knights of Columbus #9578, the town of Rowlesburg, Central Preston Middle School, and all sponsors, for all claims of damage, demands, actions whatever in any manner arising out of my participation in said athletic event. I attest and verify that I have full knowledge of the risks involved in this event and I am physically fit and sufficiently trained to participate in this event.

Signature of Applicant: ___________________________________ Date: ________

Signature of Parent: ______________________________________ Date: ________
(If under age 18)