Sunday, November 21, 2010 -- Rowlesburg, WV
Knights of Columbus Rowlesburg 10K & 5K Run
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CONTACT: David Pauly (phone) 304-282-2914 or (e-mail) dpauly@access.k12.wv.us
Entry fee $15.00 if mailed by Nov. 13, 2010, then $20.00, no refunds.
Make checks to: Knights of Columbus #9578
Mail To: David G. Pauly, Rt. 1 Box 1146, Kingwood, WV 26537
Name: ____________________________________________________________ Male: ___ Female____
Address: _________________________________________________________ Birth Date: __/___/___
City: _________________________________________________________ State: ______Zip: ______
Phone: ( )______________________ Shirt Size: S M L XL Age:______
In consideration of your acceptance of my application for entrance in the Knights of Columbus Rowlesburg 10K & 5K Run I, for myself and everyone entitled to act on my behalf, waive and release the Knights of Columbus #9578, the town of Rowlesburg, and all sponsors, for all claims of damage, demands, actions whatever in any manner arising out of my participation in said athletic event. I attest and verify that I have full knowledge of the risks involved in this event and I am physically fit and sufficiently trained to participate in this event.
______________________________________________________________________________
Signature of Applicant
Date: _______________________________
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Signature of Parent if under age 18
Date: _______________________________