Thursday, March 22, 2012 -- Fairmont, WV
Making Connections 5k Run & 2 Mile Walk
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RACE CONTACT: Ron Weist (phone) 304-367-4920 (e-mail) ron.weist@pierpont.edu
Mail to: Pierpont Community & Technical College, 320 Adams Street; Suite G-01, Fairmont, WV 26554
Please select all that apply (No Refunds):
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____ 5K Run OR 2 Mile Fun Walk . . . $15 ($20 after March 12)
____ 2 Mile Fun Walk . . . $15 ($20 after March 12)
____ Kids' K . . . FREE!!!
____ 5 Weeks to 5K Course . . . $49 (Race Fee Included)
Division (select one):
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____ Community
____ Pierpont / Fairmont State Students
____ Pierpont / Fairmont State Faculty & Staff
Name:_______________________________________________________________________
Address:____________________________________________________________________
____________________________________________________________________________
Phone: (_______________) _________________________________________
Email:____________________________________________________________
Date of Birth:____/____/________ | Age on 3/22/2012:_____ | Gender: Male___ OR Female___
WAIVER In consideration of Pierpont's allowance of my participation in this event, I agree to the extent permitted by law, to release, waive, forever discharge, and covenant not to sue Pierpont, its governing board, officers, agents, employees, and any students acting as employees, from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of actions, costs, and expenses of any nature which I may have or which may thereafter accrue to me, arising out of or related to any loss, damage, or injury, including but not limited to suffering and death, that may be sustained by me or by any property belonging to me, in connection with my participation, due to my own negligence or from incidents not specifically attributed to the negligence of Pierpont, the State of West Virginia, its employees, and officials or agents of any and all of the foregoing. I understand that my participation is voluntary and I recognize that there are risks and hazards inherent in my participation to myself and to others, and I assume all responsibility and risk associated with my participation.
I have read and understand the contents and the consequences stated in this notification.
_____________________________________________________________________________
Signature (Parent/Guardian must sign if participant is under 18 years of age.)