Sunday, November 4, 2012 -- Bridgeport, WV
1st Annual Kisingo 5K
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By entering this race, I am stating that I am medically able and properly trained for such an event. I assume all risks associated with running in this event including, but not limited to: falling, contact with other participants, effects of the weather, traffic & other road conditions, all such risks being known to and appreciated by me. Having read this waiver, and knowing these facts, and in consideration of your accepting my entry, I for myself and anyone entitled to act on my behalf, waive and release the City of Bridgeport, Harrison County Board of Education, Harrison County Fire Department and/or Harrison County Emergency Medical Squad, Cindy Kelley, Co-Director, Katie Kelley, Co-Director, all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event. I grant permission in this event to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose.Race Contact: Cindy Kelley, Co-Director....304-677-3637 or Katie Kelley, Co-Director....304-288-1608
Entry Fee: $20 before 10/28/2012 . . . $25 after 10/28/2012
Make Checks Payable to: Kisingo 5K
Mail to: 120 Crestview Terrace Apartment 7 Bridgeport, WV 26330
Last Name: _____________________ First Name: _______________________
Address: _______________________ City: _____________________________
State: _________________________ Zip: ______________________________
Phone: ________________________ email: _____________________________
Emergency Contact: _________________________________________________
Phone: ___________________________________________________________
Age on Race Date: ______ Date of Birth: (mm/dd/yy) _____/_____/_____
Gender: _____Female _____Male
Age Division (check one) __14 & Under __15-19 __20-24 __25-29 __30-34 __35-39 __40-44 __45-49 __50-59 __60+
Tshirt Size (check one) __Small __Medium __Large __Extra Large
All forms must be signed. Incomplete forms cannot be accepted.
_______________________________________________ Signature _______________________________________________ Date _______________________________________________ Signature of Parent/Guardian if entrant is under the age of 18