Saturday, September 29, 2012 -- Marlinton, WV
Possum Trot 5K Run & Walk ENTRY FORM
Return to the Details Page
RACE CONTACT: Nelson (phone) 304-799-6377
Entry Fee: Before 9/1 = $12 ... After 9/1 = $15 ... Make checks out to: Pocahontas County Chamber of Commerce
Mail to: Pocahontas County Chamber of Commerce, P.O. Box 275, Marlinton WV 24954
Last Name: ____________________________ First Name: ______________________ Address: ______________________________________________________________ City: ____________________________________ State: _________ Zip: ___________ Phone: ________________________ Email: __________________________________ Emergency Contact: ___________________________ Phone: ____________________ Age: ______ Date of Birth (mm/dd/yy): _____/_____/_____ Gender: __Male __Female Age Division (check one): __14 & under __15-19 __20-29 __30-39 __40-49 __50-59 __60+ T-Shirt Size (check one): __Small __Medium __Large __Extra-Large
All forms must be signed. Incomplete or unsigned forms will not be accepted.
I know that running a road race is a potentially hazardous activity. I should not enter and run unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all the risks associated with running in this event including, but not limited to: fall, contact with other participants, the effects of weather, including high heat and/or humidity, traffic and other conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the Pocahontas County Chamber of Commerce and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event. I grant permission in this event to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose.
_____________________________________________________________________
SIGNATURE
Date _______________________
_____________________________________________________________________
SIGNATURE of Parent/Guardian if entrant if under the age of 18
Date _______________________