Saturday, August 11, 2007 -- Saint Albans, WV / St. Albans Fire and Police Station
Thomas Memorial Hospitals 26th Annual 5K Run and Walk
Name:___________________________________________________________
Address:________________________________________________________
City, State and Zip:____________________________________________
Phone:(____________)____________________________Age 8/11/07______
Male_____ Female____ / T-Shirt Size: S____ M____ L____ XL____
Check the race you are entering: 5k Run_____ 5k Walk_____
Are you a Thomas Hospital Employee? Yes____ or No______
Are you entering the Thor & Athena Division? (Males: 185 lbs, and over and Females: 140 lbs and over) Yes____ or No______
Are you entering the Hot Wheels Division? (Formerly Wheelchair Division) Yes____ or No______
Are you entering the Corporate Team Division? (Corporate Team Division requires 3-5 members and a $50 entry fee per team) Yes____ or No______
Team Name________________________________________________
Are you a member of a Thomas Departmental Team? Yes____ or No______
Team Name________________________________________________
Are you entering a family pet(s)? If yes, list their names(s):_________________________________________________
MAIL: 1. Complete entire form; 2. Sign & date Release; 3. Mail form along with check (payable to Thomas Memorial Hospital Fitness Event) to: Thomas Memorial Hospital, Marketing and P.R. Department, 4605 MacCorkle Ave., SW, South Charleston, WV 25309
RELEASE OF RESPONSIBILITY: In consideration of your accepting this entry, I, the undersigned, intending to be legally bound hereby, for myself, my heirs, executors and administrators waive and release any and all rights and claims for damages I may have against Thomas Memorial Hospital, and any other individuals and organizations assisting with the Run and Walk, for any and all injuries suffered by me and/or my family dog in said event. I verify that I am physically fit and have sufficiently trained for the completion of this event.
____________________________________________________________
Signature (Parent to sign if under 18)