Saturday, April 16, 2011 -- Morgantown, WV / HealthSouth MountainView (Parking Lot)
HealthSouth's Cranium Crawl 5K Run & Walk ENTRY FORM
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RACE CONTACT: Michelle Reel (Phone) 800-388-2451 ext. 2307, (e-mail) Michelle.Reel@healthsouth.com
FEE: $20 per person, $18 per person if registered by March 21, 2011 (Register by this date to guarantee a shirt/goody bag.)
Payable to: Neurological Injury Prevention Program (NIPP)
Mail to: HEALTHSOUTH MountainView, C/O Michelle Reel, 1160 Van Voorhis Road, Morgantown, WV 26505
Please Print Clearly.
Name: __________________________________________________________________________
Male _____ Female _____ // Age as of 4/16/11 _______
Telephone No. (____________)________________________________
Adult shirt: Sm___ Med___ Lg___ 1XL___ 2XL___ 3XL__
Street Address: ________________________________________________________________
City: _____________________________________ State: __________ Zip: _____________
RACE SELECTION: 5K WALK ________ 5K RUN ________
WAIVER: "In consideration of this entry being accepted, I the undersigned, intending to be legally bound, for myself, my heirs, Executors and administrators waive and release any and all rights and claims for damages I may have against the sponsors of HEALTHSOUTH MountainView Rehabilitation Hospital, their representatives, successors, and assigns for any and all injuries suffered by me in said event. I attest and verify that I am physically fit and have been successfully trained for the completion of a race of this distance and difficulty."
SIGNATURE: ______________________________________________________________________
Date: _____________________________
PARENT OR GUARDIAN SIGNATURE: (if under 18)
_________________________________________________________________________________