Saturday, October 15, 2011 -- Wheeling, WV / Warwood Middle School
Auggie's 5K Run & Walk ENTRY FORM
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RACE CONTACT: Tom Rownd (phone) 216-501-2188 (e-mail) tomrunfast@comcast.net
Wind jackets with original artwork will be reserved for the first 150 registrants.
ADULT . . . $18 until 10/8/11 ($20 after 10/8/11) | YOUTH . . . age 15 and younger, $12 until 10/8/11 ($14 after 10/8/11)
Please make checks payable to: OVRWC and Mail to: Tom Rownd - AUGGIE'S 5K, 609 Chuckie Lane, Wheeling, WV 26003
Name_______________________________________________________________________
Address____________________________________________________________________
City, State, Zip___________________________________________________________
Phone: (________________________)_________________________________
Email: ___________________________________________________________
Date of Birth (month, day, year) _____/_____/__________
Age on race date (10/15/11)____________________________
_______ I would like to volunteer to help before, during,
or after the race.(Circle one or more.) Please contact me.
_______ I would like to donate $______ in memory of - or - in honor
of _______________ (pet's name)
Male _____ Female _____ Runner _____ Walker _____
Shirt Size:(circle one) XXL, XL, L, M, or S
Waiver:
In submitting this entry, I, intending to be legally bound for myself, my heirs, executors and administrators, waive, release and forever discharge any and all rights and claims which I may hereafter accrue against the Ohio Valley Runners & Walkers Club, Inc., OCSPCA, any event sponsors, event volunteers, event staff, and their officers, directors, agents, successors and/or assigns for any injuries suffered by me at this event while traveling to and from the event or while participating in it. I attest and verify that I am physically fit and sufficiently trained for the competition of this event. I understand that I may be photographed and agree to allowing my photo, video, or film likeness to be used for any legitimate purpose by the aforementioned parties.
Signature_________________________________________________________
Date______________________________
Signature_________________________________________________________
(Parents/Guardian Signature if under 18)
Date______________________________