Saturday, April 9, 2005 -- Glen Dale, WV
We Run, We Walk, For Webark (iPO Event Id#: 6810)

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• Pre-registration Fee before and by 04/01/05 = $13.00
• Late Registration Fee after 04/01/05 = $15.00
• Children Registration 15 yrs. and younger = $10.00

Mail entry forms to:
Tom Rownd c/o Race Director
609 Chuckie Lane
Wheeling, WV 26003

Name___________________________________________________

Address________________________________________________

City, State, Zip________________________________________
 

Phone____________________ Email:_______________________

Age on race date (4/9/05)_______________

Male _____ Female _____    Runner ___ Walker ___

Shirt Size:  XXL____ XL____ L____ M____ S____

___ I can't participate, but i"d like to donate $____ in memory of - or - in honor of my pet.

My Pet's Name: ______________________________

Waiver: By checking the box below, you agree, warrant and covenant as follows: In submitting this entry, I, intending to be legally bound for myself, my heirs, executors and administrations, waive, release and forever discharge any and all rights and claims which I may hereafter accrue against the Ohio Valley Runners' and Walkers' Club, Inc., Webark Estates, Inc., Reynolds Memorial Hospital, any event sponsors, event volunteers, event staff, and their officers, directors, agents, successors and/or assigns for any injuries suffered by me at this event while traveling to and from the event or while participating in it. I attest and verify that I am physically fit and sufficiently trained for the competition of this event. I understand that I may be photographed and agree to allowing my photo, video, or film likeness to be used for legitimate purpose by the afforementioned parties.

_______________________________________________________
SIGNATURE

________________________
DATE

_______________________________________________________
SIGNATURE (Parent's signature if under 18 years old)

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DATE