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Saturday, June 14, 2003 -- Fayetteville, WV
Captain Thurmond 5K & Kid's Challenge (iPO Event Id#: 5634)

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Registration Form
Name:___________________________________ Age on 6/14/03:____________

Address:____________________________________________________________

City, State Zip:____________________________________________________

Phone:__________________________________    Male:_____  Female:_____

    ____ 5K Run
    ____ 5K Walk
    ____ Kid's Challenge

T-shirt size:   Kid's L      Adult M       Adult L       Adult XL
Waiver (must be signed to participate)
I hereby release and waive the right to hold liable the Fayette Area Street & Trail Runners, Fayetteville Dairy Queen, Eric Teets State Farm Insurance, the Town of Fayetteville, New River Convention & Visitor's Bureau, Captain Thurmond Committee and all other agencies and individuals of this event from any claim for injury, damages and/or death which may occur or be sustained from my participation (or my child's/ward's participation) in this race. I certify to the above named sponsors and individuals that I (or my child or ward) understand that running is a demanding activity with many inherent dangers and that I (or my child or ward) am in proper condition to participate in this run. I further understand that health care coverage for any damages incurred as a result of my participation (or my child or ward's) in this run shall be my own responsibility, and not the responsibility of the above said sponsors, agencies, and/or individuals.
Signature:________________________________________ Date:__________

If participant under 18 years of age:

Name of parent/guardian:______________________________________

Signature:________________________________________ Date:___________

Mail to: Captain Thurmond Events, 105 Bennett Street, Oak Hill, WV 25901
The 5K entry fee is $12.00. Make checks payable to: New River CVB
The kid's running events are free, but registration is mandatory