NAME____________________________________________________________________

ADDRESS_________________________________________________________________

CITY_________________________________________STATE_______ZIP____________

PHONE (_________________)________________________________

E-MAIL __________________________________________________

AGE ON RACE DAY_________________ BIRTHDATE_______/_______/______________

MALE___ or FEMALE___

SHIRT SIZE (Please check one): S___ M___ L___ XL___ XXL___

Check the BU Sports team you would like to receive $5.00 of your registration fee.

_____Young Bucs Association     	_____Upshur Co. Youth Football
_____BUHS Cheerleaders		        _____SYC Drill Team
_____BUHS Girls Basketball		_____BUHS Boys Golf Team
_____Mountain State Girls on the Run

WAIVER: Inconsideration of allowing myself and or my minor child and entry in the event listed above I, intending to be legally bound, do hereby for myself, my heirs, executors and administrators, waiver and release forever any and all rights and claims or damages I may incur against the Young Bucs Association, their successors, representatives, assignees and free agents, for any and all injuries suffered by me or my minor child while traveling to and from and competing in the B.U.M.S. Run 5K. I grant permission to be photographed, videotaped, and recorded for any media or promotional usage. FONT>

_________________________________________________________________________
SIGNATURE  (If under 18, Parent or Guardian MUST sign)