2010 Good Samaritan Soles

5K Run/Walk Entry Form

Name (Please Print):  _____________________________________   Phone #: (__________)____________________

 

Mailing Address: _________________________________________________________________________________

 

Email Address: __________________________________________________________________

 

Male _____  Female _____    Age on 9-6-2010: _____________________

 

Circle Age Group:   14 & Under     15 to 19     20 to 24     25 to 29     30 to 34     35 to 39     40 to 44

 

                                    45 to 49     50 to 54     55 to 59     60 to 64     65 to 69     70 plus      Stroller Division

 

Circle T-Shirt Size:     S     M     L     XL     XXL      Donation / Check Amount Enclosed $______________

 

Make Checks Payable To & Mail To: Good Samaritan Center –1523 Chestnut Street–Kenova, WV 25530

                                                                                         For mailing purposes please allow 3 to 4 days for delivery                          Race Fee Is No-Refundable

 

 

WAIVER: I, undersigned, waive and release myself, my heirs, executors and administrators, any and all rights and claims for damages, demands and any other actions whatsoever, which I may have against the City of Kenova, the Town of Ceredo, The Good Samaritan Center and participating sponsors and supporters of those entities, successors, representatives and assigns, arising out of my participation in this event. Should I suffer any injury or illness, I authorize officials of this race to use their discretion to have me medically treated and transported to a medical facility and I take full responsibility for this action.

 

Participant’s Signature _________________________________________________________________________

 

 

Parent/Guardian Signature (if participant is Under 18): ____________________________________________________

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