Saturday, September 29, 2012 -- Kingwood, WV
The Buckwheat Mile
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RACE CONTACT: Paul Martin at Email: prestonrun@gmail.com or Phone 304-290-3772
Fee:
- Preston County Students registered by deadline without a t-shirt - FREE
- Preston County Students registered by deadline with a t-shirt - $7
- Out-of-county students registered by deadline without a t-shirt - $5
- Out-of-county students registered by deadline with a t-shirt - $10
- All students not pre-registered (t-shirt not guaranteed) - $12
- Adults registered by deadline without a t-shirt - $5
- Adults registered by deadline with a t-shirt - $12
- Adults not pre-registered (t-shirt not guaranteed) - $14
Make checks out to: PCPaRC
Mail to: Paul Martin, 188 Pleasantdale Road, Kingwood, WV 26537
Last Name: ____________________________ First Name: ______________________ Address: ______________________________________________________________ City: ____________________________________ State: _________ Zip: ___________ Phone: ________________________ Email: __________________________________ Emergency Contact: ___________________________ Phone: ____________________ Age: ______ On (Sept 29 2012) Gender: __Male __Female Age Division (check one): __10 & under __11-14 __15-18__19-29 __30-39 __40-49 __50-59 __60+ T-Shirt Size Adult(check one): __Small __Medium __Large __XL __ XXL T-Shirt Size Youth (check one): ____ Medium ___ Large
All forms must be signed. Incomplete or unsigned forms will not be accepted.
DISCLAIMER: I, the undersigned accept full responsibility for myself and for any injuries I may incur during the Buckwheat Mile. I have read this application and I fully understand that participating in this event may be dangerous to my health. Broken bones, cuts, bruises, heat exhaustion, collision with vehicles, other runners or pedestrians are all possibilities. I fully understand that emergency medical personnel may not be on the course. I have trained sufficiently for this event. I will not hold any of the organizers, the Preston County Parks and Recreation Commission (PCPaRC), the Kingwood Volunteer Fire Departments (KVFD), the City of Kingwood, or any volunteers of this event responsible. My actions and mishaps are accountable to no one but myself. I agree to withdraw from the race if so instructed by a race official. I grant the race organizers the free use of my name, and any photos or videos of me for any use related to the race they see fit. I acknowledge that my entry fee is non-refundable, even if the race is canceled because of an act of nature or mankind, and may be rejected for any reason that the race directors deem necessary.
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SIGNATURE
Date _______________________
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SIGNATURE of Parent/Guardian if entrant if under the age of 18
Date _______________________