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Saturday, July 30, 2005 -- Kingwood, WV
Support the Troops 5K (iPO Event Id#: 7024)

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Entry Fee & Form: $10.00 before July 22 (after July 22nd, $15.00)
(T-shirt included in entry fee.)

Make check payable to... 646th Family Readiness Group
Mail payment and entry form to:
Support the Troops, 13 Albright Road, Kingwood, WV 26537


Name:   ____________________________________________________

Address:  ___________________________________________________

___________________________________________________________

Phone:  ____________________________________________________

E-Mail Address:  _____________________________________________

Gender:  _______Male    _______Female    

Age:  _______ (as of July 30th, 2005)

Choose one event for participation:  5k Run_______  2m Walk_______

Shirt size (check only one) Med___ Large____ X-Large____ XX-Large____

Enclosed Entry Fee:   $10.00 before July 22      

Liability Wavier: I, the undersigned, waive and release myself, my heirs, executors, and administrators, any and all rights and claims for damages, demands, and my other actions whatsoever, which I may have against all participating sponsors, supporters, United States Army, 646th QM company, its' commander, the 646th Family Readiness Group, and the Preston County Country Club, arising out of my participation in this event, including all injuries, including death suffered by me as a result of my participation in this event. I deem myself sufficiently trained for the completion of this event. Should I suffer from injury or illness, I authorize officials of this event to use the discretion to have me medically treated and transported to a medical facility. I also authorize the sponsors to use any photographs or video take of me to be used in any promotional materials.

_______________________________________________________
Signature (parent or gardian MUST sign if under 18 yrs of age)


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Date