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Saturday, October 27, 2012 -- Fairmont, WV
Fairmont Gateway 5K Night Glow Run/2M Walk (iPO Event Id#: 14309)

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RACE CONTACT: Kate Green (phone)304-366-0468 (email)

** The first 150 registrants are guaranteed a T-shirt ** $15.00 - postmarked by 10/19/12 . . $20.00 - after 10/19/12 on race day

Make checks payable to: Main Street Fairmont

Mail to: Main Street Fairmont
206 Adams Street
Fairmont, WV 26554

Name: ________________________________________________________________

Address: _____________________________________________________________


Phone: (__________________) __________________________________________

E-mail: ______________________________________________________________

Age on 10/27/12 ____ . . DOB:___/___/_____ . . Male____ or Female____

5K Event: RUN____ or Walk _____ .. T-shirt Size: S___ M___ L___ XL___

WAIVER: I hereby-for myself, my executors, and my administrators-waive any and all rights and claims I may have against the City of Fairmont, Marion County, the City of Pleasant Valley or any other agency associated with this event, sponsors of this event, or suppliers 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.

Signature of Participant (Parent or guardian must sign if under 18.)