Children’s Therapy Clinic Make A Miracle 5K Walk/Run & 10K Run

 

Coonskin Park Amphitheatre, Charleston, WV - Saturday, April 21st, 9am

The course is challenging especially for the 10K (steep, uphill) We have great goody bags for runners! Proceeds go to providing free therapies for special needs children who are uninsured or underinsured.

Registration Form (please print)

 

 

Name____________________________________________________________

 

Gender:             Male                 Female             Age on day of race___________

 

 

Address:_________________________________________________________

 

Phone: (     ) ___________________            E-Mail:_______________________

 

 

Emergency Contact: _______________________________________________

                                  (name and relation)

Emergency Contact Phone: (     )______________________________________

 

 

I am registering for (circle one):               5K Walk            5K Run             10K Run

 

 

Waiver and Release of Liability Statement

 

Please carefully read the following Waiver & Release of Liability Statement, then sign your signature. 
Minors under the age of 18 on the day of the race, must have signature of their legal guardian foe participation in this event.

 

In return for permission by the Children’s Therapy Clinic to participate in the 5K Walk/Run or the 10K Run, I release the Children’s Therapy Clinic, Inc., it’s members, volunteers, sponsors, donors, and any other participant from any claim of 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____________________________________Date________________

 

T-Shirt Size                   Small                Medium             Large                X-Large

(circle one)

 

Fee:      $15.00 if postmarked by April 12th;        $20.00 thereafter.

T-Shirts guaranteed if registration is received by April 12th, thereafter by availability.

 

Mail fee and entry form to:      Children’s Therapy Clinic

                                                PO Box 2707

                                                Charleston, WV 25330

 

For more information: Call 342-9515; or E-Mail  CTCRunner@aol.com