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Saturday, August 13, 2011 -- Charleston, WV / Coonskin Park
Children's Therapy Clinic Make A Miracle 5K . 10K
ENTRY FORM
(iPO Event Id#: 13473)

Return to the Details Page

CONTACT: Valicia Leary (e-mail) valicia@childrenstherapyclinic.com

Fee: $20.00 if postmarked by July 15, $25.00 thereafter

Mail fee and entry form to:

Children's Therapy Clinic
113 Lakeview Drive
Charleston, WV 25313

Please Print

________________________________________________________________________
NAME

GENDER: ____male or ____female // Age on Race Day: _____/_____/_________

________________________________________________________________________
ADDRESS

CITY______________________________________/ STATE______/ ZIP_____________

PHONE (______________________) ___________________________________

E-MAIL____________________________________________________________

Emergency Contact________________________________________________________
(Name & Relation)

Emergency Contact Phone (________________) ________________________

I am registering for: ____5K WALK / _____5K RUN / ____ 10K RUN

T-Shirt Size (circle one): ___SMALL / ___MED / ___LG / ___XL (all adult sizes)
(T-Shirts guaranteed if registered by July 15.)

WAIVER AND RELEASE OF LIABILITY:

Please carefully read the following Waiver & Release of Liability Statement, then sign your signature.

Minors under the age of 18 MUST have signature of their legal guardian for participation in this event.

In return for permission by the Children's Therapy Clinic to participate in the 5K walk or run, or the 10K run, I release the Children's Therapy Clinic, Inc. it's members, volunteers, sponsor, donors, and any other participant from any claim for injury or loss that occurs to me, my child, my ward, or anyone else on whose behalf I am representing by my signature. In addition, I attest and verify that I am or the participant for whom I am signing is physically fit and have/has sufficiently trained for this event. I give permission to CTC to use any photo, video footage, etc that is taken during this event for use in future promotional materials.

________________________________________________________________
SIGNATURE (Parent or Legal Guardian must sign if under 18)

________________________________________
DATE