Saturday, April 23, 2011 -- Glen Dale, WV / Reynolds Memorial Hospital
Webark 5K Run & Walk ENTRY FORM
Return to the Details Page
RACE CONTACTS: Tom Rownd (e-mail) tomrunfast@comcast.net or Pam Lacefield (phone) 304-845-0855
- ** Long-sleeve T-shirts are guaranteed to the first 200 registrants **
- Mail To: Webark 5K, P.O. Box 918, Moundsville, WV 26041
- Checks payable to: Webark // Fee: $15 (Adults) or $10 (Kids age 15 & Younger)
Name______________________________________________________________________
Address___________________________________________________________________
City/State/Zip____________________________________________________________
Phone (__________)________________ E-mail:________________________________
Date of Birth (month, day, year) _____/_______/___________
Age on race date (4/23/11) ______ // Male_____ Female_____
Runner____ Walker____ // Shirt Size: 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)
________________________
DATE