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Sunday, November 20, 2011 -- Rowlesburg, WV
Rowlesburg 10K Run . 5K Run/Walk ENTRY FORM (iPO Event Id#: 13748) -- Presented by the Knights of Columbus #9578

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RACE CONTACT: David Pauly (phone) 304-282-2914 or (e-mail) dpauly@access.k12.wv.us

$15.00 if mailed by Nov. 13, 2011 . . . $20.00 after Nov. 13 and on race day, no refunds.

Make checks to: CPMS Cross Country

Mail To: David G. Pauly, Rt. 1 Box 1146, Kingwood, WV 26537

Name: ____________________________________________________________ Male: ___ Female____

Address: _________________________________________________________ Birth Date: __/___/___

City: ___________________________________________________ State: ______Zip: _____________

Phone: ( )_______________________________________

Shirt Size: S__ M__ L__ XL__ Age:______

Race (check one): 10K RUN____ or 5K RUN/WALK____

In consideration of your acceptance of my application for entrance in the Rowlesburg 5 & 10-K River Run I, for myself and everyone entitled to act on my behalf, waive and release the Knights of Columbus #9578, the town of Rowlesburg, Central Preston Middle School, and all sponsors, for all claims of damage, demands, actions whatever in any manner arising out of my participation in said athletic event. I attest and verify that I have full knowledge of the risks involved in this event and I am physically fit and sufficiently trained to participate in this event.

______________________________________________________________________________
Signature of Applicant

Date: _______________________________

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Signature of Parent if under age 18

Date: _______________________________