Saturday, November 2, 2013 -- Belington, WV
Belington Wellness Center 2nd Annual Turkey Trot
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RACE CONTACT: Marlana Pennington(Phone) 304-823-1800 , (email) mpennington@bcmsa.org
Fee:$10.00 if PostMarked By Oct 18. $15.00 after. No Refunds.
Make checks out to: Belington Wellness Center
Mail form/payment to:
Belington Wellness Center
70 N. Sturmer Street
Belington, WV 26250
Check One: 5K______ 1 Mile Turkey Wee Trot (Walk)______
Last Name: ____________________________________________________________
First Name: ___________________________________________________________
Address: ______________________________________________________________
City: _________________________________________________________________
State: _________________________ Zip: _________________________
Phone: (__________________)____________________________________
Email: ________________________________________________________
Emergency Contact Name: _______________________________________________
Phone: (__________________)____________________________________
Age: ______ Date of Birth (mm/dd/yy): _____/_____/_____ Gender: __Male __Female
T-Shirt Size (check one): Small___ //Medium___ //Large___ //Extra-Large___ //Extra-Exta Large______(Free to first 30 registered)
WAIVER: I, the undersigned, waive and release myself, my heirs, executors, and administrators, any and all rights and claims for damages, demands, and any other actions whatsoever, which I may have against the Belington Wellness Center, all participating sponsors and supporters of those entities, successors, representatives, and assigns, arising out of my participation in this event. I consider myself adequately trained for the completion of this event. Should I suffer an injury or illness, I authorize officials of this race to use their discretion to have me medically treated and transported to a medical facility and I take full responsibility for this action. no refunds.
Signature _______________________________________________________________________
Date _________________________________________________
Signature of parent/guardian if entrant is under 18:
Signature _______________________________________________________________________
Date _________________________________________________