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Winter Series 2011 - 2012 ENTRY FORM
** ONE entry form per person **

RACE CONTACTS: Cheryl Gaynor (phone) 304-348-6860, Tallman Track Club (e-mail) tallmantrackclub@yahoo.com

Cost: $20 per person, per event . . . Check Payable to: City of Charleston Parks and Recreation

Mail to: Charleston Parks and Recreation (Winter Series), 200 Baker Lane, Charleston, WV 25302

Name: ________________________________________________________________

Address: _____________________________________________________________

City/State/Zip: ______________________________________________________

Phone: (__________________)___________________________________________

E-Mail: ______________________________________________________________

DIVISION - Male_____ OR Female_____ // Walk_____ OR Run_____ OR Wheelchair_____

AGE Divisions (check one) - 14 & under____ // 15-19____ // 20-29____ // 30-39____ //

40-49____ // 50-59____ // 60-69____ // 70 & Over____

Birth Date: ________/__________/_____________________

RUN/WALK 1 OR all 3 events, NOTE!

    ALL Runners and Walkers that FINISH All Three Events will receive a Hooded Sweatshirt.

    Check for 3 events must be included with entry form. Choose size below if participating in ALL three.

    Youth: L___ OR Adult: S___ // M___ // L___ // XL___ // XXL___

Please Check All That Apply: I am participating in ...

  • Sunday, December 11, 2011 - [ Race #1 Details ]
    ____ WALK = 3000 M Walk (1.8mi) @ 1:00 pm

    ____ RUN = 5000 M Run (3.1mi) @ 2:00 pm

  • Sunday, January 8, 2012 - [ Race #2 Details ]
    ____ WALK = 4000 M Walk (2.4mi) @ 1:00 pm

    ____ RUN = 8000 M Run (4.9mi) @ 2:00 pm

  • Sunday, February 5, 2012 - [ Race #3 Details ]
    ____ WALK = 5000 M Walk (3.1Mi) @ 1:00 pm

    ____ RUN = 10,000 M Run (6.2mi) @ 2:00 pm

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 all participating sponsors and supporters and The City of Charleston, arising out of my participation in this event, including and all injuries, including death suffered me as a result 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 event to use their discretion to have me medically treated and transported to a medical facility. I also authorize the sponsors to use any photographs or video taken of me to be used in any promotional materials.

Signature:______________________________________________________________

Parent/Guardian Signature:_________________________________________________
(Required If Under 18 years of Age)

Date: __________________________________________