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Saturday, September 29, 2012 -- Clendenin, WV
Clendenin Riverview 5K Run/WALK (iPO Event Id#: 14244)

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RACE CONTACT: Kc Lovin or Christy Cayton at Ahealthyclendenin@cchcwv.com

Entry Fee: $5 8 years- 18 Years old $15 19 years old and up. postmarked after 8/31/2012 $20

Make checks Payable AHealthyClendenin Send to PO Box 45, Clendenin WV 25045

Name:____________________________________________ Phone:_______________________

Address:__________________________________________ Date of Birth:_____________

Age as of 09/29/2012:________ / Male:___ or Female:___

T-shirt size: Small:___ / Medium:___ / Large:___ / X-Large:____

T-Shirts guaranteed to first 100 registrants

Please check your choice for the event: Running_________ or Walking__________

Please carefully read the following Waiver and 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 AHealthyClendenin to participate in the 5K Run/Walk, I release AHealthyClendenin, its members, volunteers, sponsors, 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 signing the form. 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 AHealthyClendenin to use any photo, video footage, etc., that is taken during this event for use in future promotional materials.:

Emergency Contact_____________________________________________________________________ (Required) (Name and Relation)

Emergency Contact Phone:__________________________

Signature: ___________________________________________________________________

Date: __________________

Entrant's Signature Parent of Guardian, if under 18:

Signature: ___________________________________________________________________

Date: __________________