Saturday, November 2, 2013 -- Bridgeport, WV
2nd Annual Kisingo 5K
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By entering this race, I am professing to be medically able & properly trained for such an event. I assume all the risks associated with running in this event and, for myself and anyone entitled to act on my behalf, I waive and release the City of Bridgeport, Harrison County Board of Education, Bridgeport Fire Department, Bridgeport City Police, 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 10/26/2013 . . . $25 after 10/26/2013
Make Checks Payable to: Peoples Chapel Church, Kisingo Girls Center
Mail to: PO Box 187 Philippi, WV 26416
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
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