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Saturday, September 29, 2007 -- Clarksburg, WV
FBIRA Jerry Dove Memorial 5K - MAGP Sprint #8 (iPO Event Id#: 10048)

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Make checks payable to FBIRA and mail to: FBIRA 5K Committee
1000 Custer Hollow Road, Clarksburg, West Virginia 26306

NAME: ____________________________________________________

ADDRESS: _________________________________________________

TELEPHONE:________________________________________________ AGE AS OF 9/29/2007:______________ MALE _____ FEMALE _____ KIDS-K PARTICIPANT Amount enclosed with application: $__________ T-SHIRT SIZE: SM____ MED____ LG____ XL____ Youth sizes will be provided if KIDS K Participant

RELEASE STATEMENT: In consideration of acceptance of this entry, I waive any and all claims for damages which may result from my participation, or from the participation of the minor that I am signing for in the FBI Jerry Dove Memorial 5K. Any and all claims are waived for myself, heirs and assigns. The sponsors, their agents or representatives, and/or property owners where the event is being held will assume no obligation for injuries or damages that may be incurred.

_________________________________________________________
Signature of Runner

__________________________________________________________
Signature of Parent or Guardian
(if applicant is under 18 years of age)