Winter Series 2011 - 2012 ENTRY FORM
** ONE entry form per person **
RACE CONTACTS: Cheryl Gaynor (phone) 304-348-6860, Tallman Track Club (e-mail) tallmantrackclub@yahoo.com
Cost: $20 per person, per event . . . Check Payable to: City of Charleston Parks and Recreation
Mail to: Charleston Parks and Recreation (Winter Series), 200 Baker Lane, Charleston, WV 25302
Name: ________________________________________________________________
Address: _____________________________________________________________
City/State/Zip: ______________________________________________________
Phone: (__________________)___________________________________________
E-Mail: ______________________________________________________________
DIVISION - Male_____ OR Female_____ // Walk_____ OR Run_____ OR Wheelchair_____
AGE Divisions (check one) - 14 & under____ // 15-19____ // 20-29____ // 30-39____ //
40-49____ // 50-59____ // 60-69____ // 70 & Over____
Birth Date: ________/__________/_____________________
RUN/WALK 1 OR all 3 events, NOTE!
-
ALL Runners and Walkers that FINISH All Three Events will receive a Hooded Sweatshirt.
Check for 3 events must be included with entry form. Choose size below if participating in ALL three.
Youth: L___ OR Adult: S___ // M___ // L___ // XL___ // XXL___
Please Check All That Apply: I am participating in ...
- Sunday, December 11, 2011 - [ Race #1 Details ]
____ WALK = 3000 M Walk (1.8mi) @ 1:00 pm____ RUN = 5000 M Run (3.1mi) @ 2:00 pm
- Sunday, January 8, 2012 - [ Race #2 Details ]
____ WALK = 4000 M Walk (2.4mi) @ 1:00 pm____ RUN = 8000 M Run (4.9mi) @ 2:00 pm
- Sunday, February 5, 2012 - [ Race #3 Details ]
____ WALK = 5000 M Walk (3.1Mi) @ 1:00 pm____ RUN = 10,000 M Run (6.2mi) @ 2:00 pm
WAIVER -- I, the undersigned, waive and release myself, my heirs, executors, and administrators, any and all rights and claims for damages, demands, and any other actions whatsoever, which I may have against all participating sponsors and supporters and The City of Charleston, arising out of my participation in this event, including and all injuries, including death suffered me as a result of my participation in this event. I consider myself adequately trained for the completion of this event. Should I suffer an injury or illness, I authorize officials of this event to use their discretion to have me medically treated and transported to a medical facility. I also authorize the sponsors to use any photographs or video taken of me to be used in any promotional materials.
Signature:______________________________________________________________
Parent/Guardian Signature:_________________________________________________
(Required If Under 18 years of Age)
Date: __________________________________________