Saturday, October 6, 2012 -- Charleston, WV / Little Creek Park, South Charleston, WV
Run 2 Remember 5k Trail Run/Walk
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RACE CONTACT:Brandon Merritt (e-mail) run2remember5k@gmail.com
$10 if entry received by Oct. 3rd, $15 race day
Please make checks payable to: Alzheimers Association
Mail to: Run 2 Remember 5k c/o Brandon Merritt 637 Jane St. Charleston, WV 25302
Name_______________________________________________________________________ Address____________________________________________________________________ City, State, Zip___________________________________________________________ Phone: (________________________)_________________________________ Email: ___________________________________________________________ Date of Birth (month, day, year) _____/_____/__________ Age on race date (10/06/12)____________________________ Male _____ Female _____ Registration Fee: $_______ Additional Donation for Team Run 2 Remember: $_______ Total Enclosed: $_______Waiver: I hereby for myself, my executors, and my administrators waive any and all rights and claims I may have against the Run 2 Remember 5k, individuals associated with this event, sponsors of this event, or suppliers of this event for injury or damages suffered by me and which may arise out of or in any way be connected with this event. I knowingly assume all risks involved in this event.
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(Parents/Guardian Signature if under 18)
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