Saturday, May 14, 2011 -- Keslers Cross Lanes, WV / New bridge at the end of Doc Bailey Road
Poca River 15K Road Race ENTRY FORM
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RACE CONTACT: Kelly McGraw (phone) 304-346-0470 (e-mail) runninkel@aol.com
Fee $15.00 Pre-Entry, $20.00 Race Day
Payable/Send To: Poca River Run, 9 33rd Street SE, Charleston, WV 25304
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NAME
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AGE ON MAY 14, 2011 SEX // M or F
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ADDRESS
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CITY STATE ZIP CODE
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TELEPHONE NUMBER
CIRCLE SHIRT SIZE (circle one): Small Medium Large XLarge
WAIVER:
MUST BE SIGNED OR ENTRY WILL NOT BE ACCEPTED IN CONSIDERATION OF THE ACCEPTANCE IN THE POCA RIVER 15K ROAD RACE.FOR MYSELF, MY HEIRS, EXECUTERS AND ADMINISTRATORS, I HEREBY RELEASE ANY AND ALL RUNNERS, THE SPONSORS OR THE COUNTY OR STATE IN WHICH THIS RACE IS CONTESTED. I ATTEST AND VERIFY TO THE BEST OF MY KNOWLEDGE, MY PHYSICAL CONDITION AND FITNESS ARE ADEQUATE FOR ME TO SAFELY COMPETE, AND NO PHYSICIANS OR QUALIFIED INDVINDIUAL HAS ADVISED ME AGAINST COMPETING IN THE POCA RIVER 15K. THIS ALSO IS A SIGNED WAIVER OF LIABILITY THAT RELEASES THE RACE ORGANIZERS, VOLUNTEERS, OFFICIALS AND USATF FROM CLAIMS FOR DAMAGES.
____________________________________________________________________________ SIGNATURE (Parent/Guardian MUST sign if runner is under 18 years of age)