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Saturday, September 29, 2007 -- Clarksburg, WV
FBIRA Jerry Dove Memorial 5K - MAGP Sprint #8 (iPO Event Id#: 10048)

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Make checks payable to FBIRA and mail to: FBIRA 5K Committee
1000 Custer Hollow Road, Clarksburg, West Virginia 26306

NAME: ____________________________________________________

ADDRESS: _________________________________________________

TELEPHONE:________________________________________________ AGE AS OF 9/29/2007:______________ MALE _____ FEMALE _____ KIDS-K PARTICIPANT Amount enclosed with application: $__________ T-SHIRT SIZE: SM____ MED____ LG____ XL____ Youth sizes will be provided if KIDS K Participant

RELEASE STATEMENT: In consideration of acceptance of this entry, I waive any and all claims for damages which may result from my participation, or from the participation of the minor that I am signing for in the FBI Jerry Dove Memorial 5K. Any and all claims are waived for myself, heirs and assigns. The sponsors, their agents or representatives, and/or property owners where the event is being held will assume no obligation for injuries or damages that may be incurred.

Signature of Runner

Signature of Parent or Guardian
(if applicant is under 18 years of age)