Saturday, July 16, 2011 -- Bartow, WV
Durbin Days Back Road 5K ENTRY FORM
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RACE CONTACT: Mike Stennes (phone) 304-456-3217 (e-mail) mstennes@yahoo.com
$8.00 - Pre-Registration Fee, must be received before July 10, 2011
$10.00 - After July 10 and on Race Day
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 16, 2011: _____ Date of Birth ____/____/_____
Check 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 16, 2011. 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