Saturday, March 17, 2012 -- Morgantown, WV
MountainEAR 5K ENTRY FORM
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RACE CONTACT; Lindsay Yurisko (Email) lyurisko@gmail.com
[ Register Online ] with Raceit.com or fill out this entry form, print and mail in.
Entry Fees: $15 pre-registered by March 10th, or $20 thereafter ... Checks payable to: WVU Student Academy of Audiology
Mail to: WVU SAA c/o Dr. Callahan, P.O. Box 6122, Morgantown, WV 26505
Questions? E-mail westvirginiaaud@gmail.com
PLEASE PRINT - (APPLICATION MUST BE SIGNED)
NAME:_______________________________________________________________________________
ADDRESS:____________________________________________________________________________
CITY:___________________________________________________STATE:______ZIP:____________
PHONE: (____________)___________________________________
E-Mail ADDRESS:__________________________________________
AGE ON 3/17/12:______ MALE:______ FEMALE:_______ // Date of Birth:________________
T-SHIRT SIZE: ADULT: S__ M__ L__ XL__ XXL ____ // CHILD: S__ M__ L__
Waiver of Liability: In consideration of your acceptance of my application for entrance in The MountainEAR 5K , I, for myself and anyone entitled to act on my behalf, waive and release the WVU Student Academy of Audiology, all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my or my child's participation in this event.
___________________________________________________________________________________
Participant's Signature (Parent or Guardian signature if under 18 years old)