Sunday, May 4, 2008 -- Mullens, WV / Mullens Opportunity Center, 100 Front Street
The Coal Classic Heritage 5K
(Please print neatly)
NAME (first)_______________________________________________________________
(last)_______________________________________________________________
DATE OF BIRTH____________ // AGE___________
ADDRESS
(street)_____________________________________________________________
(county)____________________________________________________________
(city)_______________________________________________________________
(state)_____________________________________________________________
(zip code)____________________________________
PHONE (______________)____________________________________________
E-MAIL____________________________________________________________
T-SHIRT SIZE (please circle): S M L XL XXL
WAIVER All participants in the Coal Heritage 5K Series: Mullens Dogwood Race and related events are required to assume all risk of participation in the race by signing this general release agreement. The participant represents and warrants that he/she is in good physical condition and is able to safely participate in the race. Participant is aware of the risks and hazards involved with 5k run/walks. Participants consent to use their name and photo for media purposes. Registration fee is nonrefundable.
__________________________________________________________________
Signature of Participant // Date
__________________________________________________________________
Or parent if participant is under 18