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Saturday, August 13, 2011 -- Fairmont, WV
Union Mission 5K ENTRY FORM (iPO Event Id#: 13538)

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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: _______________________________________________________________


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.

Signature of Runner


Signature of Parent or Guardian