Saturday, August 4, 2012 -- Charleston, WV / Coonskin Park
Children's Therapy Clinic 5K Run/Walk and 10K Run
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CONTACT: Mark Robison (e-mail) mrobinson@fsblaw.com
Fee: $20.00 if postmarked by July 10, $25.00 thereafter
Mail fee and entry form to:
Children's Therapy Clinic
113 Lakeview Drive
Charleston, WV 25313
Please Print
________________________________________________________________________
NAME
GENDER: ____male or ____female // Age on Race Day: _____/_____/_________
________________________________________________________________________
ADDRESS
CITY______________________________________/ STATE______/ ZIP_____________
PHONE (______________________) ___________________________________
E-MAIL____________________________________________________________
Emergency Contact________________________________________________________
(Name & Relation)
Emergency Contact Phone (________________) ________________________
I am registering for: ____5K WALK / _____5K RUN / ____ 10K RUN
T-Shirt Size (circle one): ___SMALL / ___MED / ___LG / ___XL (all adult sizes)
(T-Shirts guaranteed if registered by July 10.)
WAIVER AND RELEASE OF LIABILITY:
Please carefully read the following Waiver & Release of Liability Statement, then sign your signature.
Minors under the age of 18 MUST have signature of their legal guardian for participation in this event.
In return for permission by the Children's Therapy Clinic to participate in the 5K walk or run, or the 10K run, I release the Children's Therapy Clinic, Inc. it's members, volunteers, sponsor, donors, and any other participant from any claim for injury or loss that occurs to me, my child, my ward, or anyone else on whose behalf I am representing by my signature. In addition, I attest and verify that I am or the participant for whom I am signing is physically fit and have/has sufficiently trained for this event. I give permission to CTC to use any photo, video footage, etc that is taken during this event for use in future promotional materials.
________________________________________________________________
SIGNATURE (Parent or Legal Guardian must sign if under 18)
________________________________________
DATE