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Saturday, November 5, 2011 -- Wheeling, WV
Veterans Day 10K Run/Walk ENTRY FORM (iPO Event Id#: 13398)

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RACE CONTACT: Hugh Stobbs (phone) 304-242-7322

    Late & Race Day Entry - Registration will be at Bridge Street Middle School on Friday from 5 PM to 7 PM and race day from 7 AM until start of the race.

    Military Personnel and Veteran Participants - Veterans or military personnel are exempt from entry fee but must still send in a completed entry form. They will receive red, white, and blue race numbers to distinguish them from the other participants, a free banquet entry/meal, and t-shirt.

    Non-Military Participants - Entry fee must accompany each application. Racers get an official race T-shirt, free admission to the awards banquet inside WesBanco Arena beginning at 11:30 AM. Additional banquet tickets available at registration desk for $10.50 each. Shower facilities available at Center Town Fitness.

    Payable to: Veterans Day 10K . . . Mail to: HUGH STOBBS, RACE DIRECTOR, P.O. Box 2193, Wheeling WV 26003

PLEASE CHECK ONE:

______ FREE (Military Personnel & Veteran Participants ONLY)
______ $20 postmarked by Oct. 28, 2011
______ $25 after Oct. 28, 2011
______ $25 Friday Nov. 4, 2011 or Race Day (Saturday Nov. 5, 2011)

FIRST NAME: ______________________________________________________________________

LAST NAME: _______________________________________________________________________

AGE ON 11/05/11:________ // SEX: MALE_____ OR FEMALE_____ // WALK:_____ OR RUN:_____

STREET ADDRESS:____________________________________________________________________

CITY:____________________________________________ STATE:__________ ZIP:____________

PHONE: (________________)_________________________________________

BIRTH DATE: ___________/_____________/____________________________

BRANCH OF SERVICE PAST OR PRESENT:__________________________________________________

WAIVER (to be signed by athlete and by parent or guardian)*

For and in consideration of permission granted to me for my participation in the Veterans Day 10K Run/Walk at Wheeling, West Virginia, and other valuable considerations, the receipt and sufficiency of which are hereby acknowledged: I hereby agree on behalf of myself, my heirs, executors, administrators, and assigns to release and discharge the chairman and all officers, agents and employees of and volunteers associated with the Veterans Day 10K Run/Walk, OVMC, Health Plan, Progressive Bank, Ohio County Commission and City of Wheeling, its officials, officers, agents and employees, jointly and severally, from any and all claims, demand, actions, judgments and executions under which I ever had, now have, or may have against any or all of the aforesaid, any combination of the aforesaid, their successors and assigns jointly or severally for all personal injuries, known or unknown, as well as all damages to property, real or personal caused by or arising out of my participation in the Veterans Day 10K Run /Walk at Wheeling, West Virginia.

Further and in consideration of permission granted to me for my participation in the Veterans Day 10K Run/Walk at Wheeling, West Virginia, and other valuable consideration, receipt of which is hereby acknowledged. I hereby agree on behalf of myself, my heirs, executors, administrators and assigns to indemnify any, all or any combination of the aforesaid jointly and severally and to hold and save harmless from and against and all actions, claims, demands, liabilities, loss damage, or expense of whatever kind and nature, including attorney fees, which may at any time be incurred by reason of my participation in or preparation for the aforesaid Veterans Day 10K Run/Walk.

ATHLETE:_____________________________________________________________________

PARENT OR GUARDIAN*:_________________________________________________________
(*For runners OR walkers under 18 years of age)