Saturday, August 13, 2011 -- Fairmont, WV
Union Mission 5K ENTRY FORM
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CONTACT: Kris Ervin, (phone) 304-363-0300
Make Checks Payable to: West Virginia Rescue Ministries
Mail Payment and Application to:
WVRM / Attn: 5K Race
107 Jefferson Street
Fairmont, WV 26554
Entry Fees:
- $13 per runner if payment is received on or before August 5, 2011
- $15 per runner after August 5, 2011
Name: _______________________________________________________________________
Address: ____________________________________________________________________
City/State/Zip: _______________________________________________________________
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Phone: (__________________)________________________________________
Male: _______ or Female: ________
Age on 8-13-2011: _____________ Date of birth: ________________
T Shirt Size: (Circle one only) Adult XL.. | Adult L.. | Adult M.. | Adult S
RELEASE:In consideration of acceptance of this entry, I waive any and all claims for damages that may result from my participation in this race. Any and all claims are waived for myself, heirs, and assigns. The sponsors and their agents or representatives will assume no obligation for injuries or damages that I may incur.
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Signature of Runner
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Date
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Signature of Parent or Guardian
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Date