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Saturday, April 28, 2012 -- Morgantown, WV
Parents' Place 5K Run/Walk ENTRY FORM (iPO Event Id#: 13870)

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RACE CONTACT: April Oliverio (phone) 304-216-2119 (email)

Entry Fee: $18 before April 16, 2012, $20 thereafter. Fees are nonrefundable.

Make checks payable to: Parents' Place ... Mail to: April Oliverio, 908 Suncrest Place, Morgantown, WV 26505

Name:____________________________________________ Phone:_______________________

Address:__________________________________________ Date of Birth:_____________

Age as of 4/28/12:________ / Male:___ or Female:___

Additional Donation for Parents' Place Scholarship Fund: $1.00_____ $5.00______ Other $______

T-shirt size: Small:___ / Medium:___ / Large:___ / X-Large:____

Please check your choice for the event: Running_________ or Walking__________

In consideration of your acceptance of my application for entrance in the Parents' Place 5K, I, for myself and anyone entitled to act on my behalf, waive and release Parents' Place and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event. I also release any photos that may involve myself::

Signature: ___________________________________________________________________

Date: __________________

Entrant's Signature Parent of Guardian, if under 18:

Signature: ___________________________________________________________________

Date: __________________