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Saturday, March 17, 2012 -- Morgantown, WV
MountainEAR 5K ENTRY FORM (iPO Event Id#: 13836)

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RACE CONTACT; Lindsay Yurisko (Email) lyurisko@gmail.com

[ Register Online ] with Raceit.com or fill out this entry form, print and mail in.

Entry Fees: $15 pre-registered by March 10th, or $20 thereafter ... Checks payable to: WVU Student Academy of Audiology

Mail to: WVU SAA c/o Dr. Callahan, P.O. Box 6122, Morgantown, WV 26505

Questions? E-mail westvirginiaaud@gmail.com


PLEASE PRINT - (APPLICATION MUST BE SIGNED)

NAME:_______________________________________________________________________________

ADDRESS:____________________________________________________________________________

CITY:___________________________________________________STATE:______ZIP:____________

PHONE: (____________)___________________________________

E-Mail ADDRESS:__________________________________________

AGE ON 3/17/12:______ MALE:______ FEMALE:_______ // Date of Birth:________________

T-SHIRT SIZE: ADULT: S__ M__ L__ XL__ XXL ____ // CHILD: S__ M__ L__

Waiver of Liability: In consideration of your acceptance of my application for entrance in The MountainEAR 5K , I, for myself and anyone entitled to act on my behalf, waive and release the WVU Student Academy of Audiology, all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my or my child's participation in this event.

___________________________________________________________________________________
Participant's Signature (Parent or Guardian signature if under 18 years old)