Saturday, July 21, 2012 -- Sutton, WV / Sutton Dam
That Dam Race 5K ENTRY FORM
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RACE CONTACT: Tammy Dickens nad/or Dustin Smyth (phone) 304-765-6533 (e-mail) info@braxtonwv.org
You can also [ Register Online ] with TriStateRacer.com
Pre-registration fee is $15 if mailed, but costs $20 on race day (July 21).
Mail entry form/check to:
Braxton County Convention and Visitors Bureau (CVB)
245 Skidmore Lane
Sutton, WV 26624
PLEASE PRINT
Name:________________________________________________________________________________
Address:_____________________________________________________________________________
City/State/Zip:______________________________________________________________________
Phone:(______________)________________________________________
E-mail:_______________________________________________________
Age: ____ // Gender: ___Male ___Female // Shirt Size*: S___ M___ L___
*(first 100 paid entries will receive shirts)
Waiver: In consideration of acceptance of this entry to the Mountain Lakes Festival 5K Run and walk, I waive all claims for myself, my heirs and assigns against the race sponsors, promoters, or officials due to injury or illness which may result from my participation. I am physically fit, and sufficiently trained to participate. I have read the above statement, I understand it, and my signature confirms its full acceptance.
_____________________________________________________________________________________
Signature . . . (Parent or guardian must sign if under 18 years of age)
____________________________________
Date