Sunday, March 28, 2010 -- Bruceton Mills, WV / Coopers Rock State Park
Coopers Rock 10K Run/5K Walk (iPO Event Id#: 12651)
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Make checks to and mail to: W.Va. TRACK CLUB, PO BOX 4159, Morgantown, WV 26504

(Please Print Legibly - Enter All Applicable Information & Sign)

                                        

NAME________________________________________________   MALE ___  FEMALE ___

ADDRESS_____________________________________________   Birthdate____/____/____
                                                       mm / dd /yyyy   
       _____________________________________________   T-SHIRT M__ L__ XL__

PHONE  _____________________________________________
                                              
EVENT    10K Run ____  5K Walk ____

Waiver - Must Sign: In consideration of your acceptance of my application for entrance in the Cooper's Rock 10K Run & 5K Walk, I, for myself and anyone entitled to act on my behalf, waive and release the Morgantown Roadrunners/West Virginia Track Club, and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event.

_________________________________________________________________________
Signature of Entrant (Required)

_________________________________________________________________________
Signature of Guardian (if under 18)