Saturday, August 14, 2010 -- Logan, WV / Chief Logan State Park
Chief Logan 5K Run & 2 Mile Competitive Walk ENTRY FORM
CONTACT: Logan County Chamber of Commerce, Phone: (304) 752-1324
5K Run Fee - Registration is $15 if postmarked by July 30,2010/ $20 thereafter and one race day
2 Mile Competitive Walk Fee - Registration Fee is $10 if postmarked by July 30, 2010/ $15 thereafter and one race day
Make checks payable to: Logan Co. Chamber of Commerce
Send checks/money orders and completed entry forms to:
Logan Co. Chamber of Commerce
PO Box 218
Logan, WV 25601
Name _____________________________________________________________________________
Date of Birth_________________
Address___________________________________________________________________________
City/State/ZIP____________________________________________________________________
Phone (____________________) __________________________________
E-MAIL ________________________________________________________
Circle your T-SHIRT SIZE: Small | Medium | Large | X Large | XX Large
SEX, Circle one: Male or Female --- AGE on Day of Race: _______
Choose your EVENT below and circle your AGE GROUP:
I choose the 5K Run (circle one age group):
14 & under, 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, 70 & Over
I choose the 2 Mile Competitive Walk/ (circle one age group):
9 & under, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70 & Over
** The following WAIVER must be signed or entry will not be accepted. **
Waiver: In consideration of your accepting this entry, I, the undersigned, intending to be legally bound, hereby, for myself, my heirs, executors, and administrators, waive and release any and all rights and claims for damages I may have against the Chief Logan Competitive 5K Run/Walk, its organizing committee or its sponsors, the Chief Logan State Park, the City of Logan, the County of Logan, the State of West Virginia, and volunteers of the race, their representatives, successors and assignors, of any and all injuries suffered by me in said event. I attest and verify that I am physically fit and have trained for the competition of this race and my physical condition has been verified by a licensed medical doctor.
Additionally, I agree to release any photographs of myself taken during the race for promotional purposes.
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Signature
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Date
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Signature (Parent or guardian signature required for those under 18 years of age)
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Date