Sunday, August 5, 2012 -- Morgantown, WV / Gene's Place, South Park
Gene's Run For Special Olympics WV - MAGP #8 ENTRY FORM
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CONTACT: Debbie McCord (phone) 304-292-4126
$17.00 if paid by July 31, and $20.00 thereafter and on race day
Checks payable to: Monongalia County Special Olympics
Mail to: Gene's Run for Special Olympics, P.O. Box 41, Morgantown, WV 26505
Run ___ . . . Grand Prix Entrant ___ . . . Walk ___
Name: ___________________________________________________________________________
Female ___ Male ___ // Age on 7/31/12: _______ Birth Date: ____ /____ /____
T-Shirt Size: L ___ XL ___ XXL ___
Address: ________________________________________________________________________
Street: _________________________________________________________________________
City/State/Zip: _________________________________________________________________
Phone (______________) _____________________________________
WAIVER: In return for permission by the Monongalia County Special Olympics to participate in Gene's 4 mile run or walk, I release the program, its members, volunteers, co-sponsors, and other participants from any claim for injury or loss that occurs to me or my child/ward or anyone on his or her behalf. I therefore attest and verify that I am physically fit and have sufficiently trained for this event.
______________________________________________________________________
Signature *
* Parents signature required if contestant is under 18 years of age).