Saturday, April 28, 2012 -- Morgantown, WV
Parents' Place 5K Run/Walk ENTRY FORM
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RACE CONTACT: April Oliverio (phone) 304-216-2119 (email) april_slokan@yahoo.com
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: __________________