Sunday, November 18, 2012 -- Rowlesburg, WV
K of C Rowlesburg 10k and 5k Run
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RACE CONTACT: David Pauly (phone) 304-282-2914 or (e-mail) dpauly@access.k12.wv.us
$20.00 if mailed by Nov. 10, 2012 . . . $25.00 after Nov. 10 and on race day, no refunds.
Make checks to: CPMS Cross Country
Mail To: David G. Pauly, 603 Borgman Rd., Kingwood, WV 26537
Name: ____________________________________________________________ Male: ___ Female____
Address: _________________________________________________________ Birth Date: __/___/___
City: ___________________________________________________ State: ______Zip: _____________
Phone: ( )_______________________________________
Shirt Size: S__ M__ L__ XL__ Age:______
Race (check one): 10K RUN____ or 5K RUN/WALK____
In consideration of your acceptance of my application for entrance in the Rowlesburg 5 & 10-K River Run I, for myself and everyone entitled to act on my behalf, waive and release the Knights of Columbus #9578, the town of Rowlesburg, Central Preston Middle School, and all sponsors, for all claims of damage, demands, actions whatever in any manner arising out of my participation in said athletic event. I attest and verify that I have full knowledge of the risks involved in this event and I am physically fit and sufficiently trained to participate in this event.
______________________________________________________________________________
Signature of Applicant
Date: _______________________________
______________________________________________________________________________
Signature of Parent if under age 18
Date: _______________________________