Saturday, May 28, 2011 -- Summersville, WV / Summersville Baptist Church, Main Street
Run To Remember ENTRY FORM
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RACE CONTACT: Allen Stump (phone) 304-590-2855, (e-mail) astump10@gmail.com
Entries should be received by May 25, 2011
Make checks payable to: Nicholas County High School
Mail to: Allen Stump (Race Director), 30 Grizzly Lane, Summersville, WV 26651
Method of Payment . . . All entry fees are non refundable!
_____ Check (make checks to NCHS Athletic Department)
_____ Cash (only for Same Day Registration)
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SIGN-UP FOR:
- _____ Children's Fun Run 10 & Under (9 am/$5.00)
- _____ RUN Get Fit Stay Fit Member 5K (8 am/$10.00)
- _____ WALK Get Fit Stay Fit Member 5K (8:05 am/$10.00)
- _____ RUN Student 5K (8 am/$12.00)
- _____ WALK Student 5K (8:05 am/$12.00)
- _____ 5K RUN (8 am/$15.00)
- _____ 5K WALK (8:05 am/$15.00)
- _____ Same Day Registration RUN 5K (8 am/$20.00)
- _____ Same Day Registration WALK 5K (8:05 am/$20.00)
- ___________ TOTAL
All entry fees are non refundable! T-Shirts are guaranteed to the first 125 registered. Fabric markers will be provided during registration. T-Shirts will only be given to those entering the 5K run/walk.
NAME: ______________________________________________________________________________
ADDRESS: ___________________________________________________________________________
____________________________________________________________________________________
PHONE: (_____________________)_____________________________________________
E-MAIL: ____________________________________________________________________
GENDER: male ______ OR female ______ // DOB Age on May 28, 2011: ______________
T-SHIRT SIZE (Check One): SM ____ MED ____ LG ____ XLG ____ XXLG ____
WAIVER: For and in consideration of my participation in the Run To Remember 5K race, I, the undersigned, release forever the sponsors, the program, its members, volunteers, co-sponsors, landowners, race organizers, race directors, other participants and all those associated with the Run To Remember 5K race from any claim for harm, injury or loss that occurs to me or my child/ward or anyone on his/her behalf as a result of participation in this event. I therefore attest and verify that I am physically fit and have sufficiently trained for this event and am aware of the potential dangers.
____________________________________________________________________________________
SIGNATURE
DATE:_________________________________
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SIGNATURE OF PARENT/GUARDIAN IF MINOR
DATE:_________________________________