Saturday, April 30, 2011 -- Jane Lew, WV
General Lightburn Consol Energy 5K, 1M Lightning Run ENTRY FORM
Return to the Details Page
RACE CONTACT: David J. Gallien (phone) 304-884-7811 (e-mail) janelew@3wlogic.net
Fee: $10.00 for each race if registered by April 20th, $12.00 thereafter
T-shirt guaranteed to pre-register runners, and as available on race day.
Payable to: Jane Lew Lions Club and Mail to:
Crestview Manor Nursing & Rehab, c/o David J. Gallien
P.O. Box 967
Jane Lew, WV 26378
NAME: Last__________________________________ First___________________________________
ADDRESS:_______________________________________________________________________________
CITY, STATE, ZIP_______________________________________________________________________
PHONE:_________________________________________________________________________________
Age:___________ Male_______ OR Female_____ // SHIRT SIZE: ___M ___L ___XL ___XXL
WHICH RACE(S) ARE YOU REGISTERING? ONE MILE__________ 5K____________
WAIVER: In consideration of this entry being accpeted. I waive for myself, my heirs and assigns, all claims for damages which I might have against the race, its sponsors, or any other organizations, business or individual as a result of any and all injuries which might be received during the contest. I also release any photos that may involve myself.
SIGNATURE REQUIRED:________________________________________________________________
PARENTS MUST ALSO SIGN IF RUNNER IS UNDER 18 YEARS