Saturday, September 15, 2007 -- Charleston, WV / Kanawha State Forest
Dream Run '07 for Make-A-Wish (iPO Event Id#: 10403)

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MAKE CHECKS PAYABLE TO/ KANAWHA VALLEY CHAPTER OF CREDIT UNIONS

Complete the following application and sign the waiver at the bottom and return it with the proper entry fee to:
Dream Run 2007, 1830 Roxalana Rd, Dunbar, WV 25064

Please complete all items including T-shirt size and the event you will be participating in.

Name: _________________________________________________________

Address: ______________________________________________________

City: ______________________ State: _______ Zip: ______________

Telephone: __________________________ T-shirt size: S M L XL XXL

Sex: _______ Age on race day: _________ 

Event (circle): 5K Run 2 Mile Walk

In case of emergency, contact _________________________________ 

Emergency phone: ______________________________________________

In consideration of acceptance of my entry in the Dream Run 2007, for myself, my heirs, executors, administrators, I hereby release and forever discharge the Park Service, their personnel, the Kanawha Valley Chapter of Credit Unions, the Make-A-Wish Foundation, volunteers, sponsors, along with the producers of this event, their representatives, successors, and assignees, from all liabilities, actions, claims, demands, damages, costs, and expenses, which I may now or in the future have against any of them arising from my participation in this event, enroute to or from the event, and including, but not limited to, any or all injuries that may be suffered by me. I attest and verify that to the best of my knowledge, my physical condition and fitness are adequate for me to safely compete in this event and that no physician or other qualified individual has advised me against participating.

My signature affirms that I have read and understand these conditions.

Entrant: ______________________________________________________ 

Date: ________________________________

_______________________________________________________________
Parent/Guardian signs if entrant is under 18

Date: ________________________________

The Make-A-Wish Foundation® of Greater PA and Southern WV advises you that a copy of the official registration and financial information may be obtained from the WV Secretary of State, State Capitol, West Virginia 25305 Registration does not imply endorsement.