West Virginia Black Walnut Festival

Spencer, West Virginia

October 12th-15th, 2017

2016 BLACK WALNUT FESTIVAL
ANNUAL 5K NUT RUN AND WALK

 


MAIL ENTRY FORM AND FEE TO:  THE FITNESS COMPLEX   200 HOSPITAL DRIVE   SPENCER, WV 25276

PLEASE CHECK ONE:  RUNNER ______________    WALKER ____________

PLEASE CIRCLE METHOD OF PAYMENT:   VISA        MASTERCARD      CHECK

CREDIT CARD #______________________________________________________________ EXP. DATE ___________________________
WAIVER: BY SIGNING BELOW, I UNDERSTAND THAT I WAIVE ALL RIGHTS                           
 AND CLAIMS FOR ANY DAMAGE OR INJURIES THAT I, MY HEIRS OR MY ASSIGNS                __________________________________________________________
MAY HAVE AGAINST THE WV BLACK WALNUT FESTIVAL, ROANE GENERAL HOSPITAL,         NAME
THE FITNESS COMPLEX, THEIR OFFICERS OR THEIR REPRESENTATIVES, ASSIGNS       __________________________________________________________
OR AGENTS, AS A RESULT OF MY PARTICIPATION IN THIS EVENT.  I ALSO CERTIFY      ADDRESS
THAT I HAVE ADEQUATELY TRAINED FOR THIS EVENT, AND AM NOT SUFFERING                 __________________________________________________________
FROM ANY INJURY OR OTHER CONDITION WHICH MIGHT SERIOUSLY BE                                                                                                                                                                                 AGGRAVATED BY MY PARTICIPATION IN THIS EVENT.                  __________________________________________________________                                                                                                                                       CITY        STATE            ZIP                                                                                                
____________________________________________________________________________        T SHIRT SIZE:    S        M        L       XL         2XL
SIGNATURE                                         
                                    SEX:    M    OR     F       
____________________________________________________________________________     
SIGNATURE OF PARENT OR GUARDIAN IF UNDER 18                AGE ON RACE DAY: ________________________

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