EmailMe Form - “Miracle Focused, Color Driven”

“Miracle Focused, Color Driven”

5k Color Run and Walk to benefit Children's Miracle Network

August 22, 2015 at Grand Vue Park in Moundsville, WV
Registration starts at 9:00am
Race starts at 10:00am

Pricing:
Children ages 6 & under - Free
Children ages 7 to 11 - $15
Ages 12 & up are as follows:
Pre-Registration - $25 (ends July 31st)
Registration - $30 (August 1 - August 19)
Day of Race - $35

Make checks payable to: Bayer HFCU

T-shirts are guaranteed to those who pre-register. Pricing for children 11 & under does not include a t-shirt. Those who do not register by July 31st may wear a white t-shirt. Individual color packets will be available to purchase for $3.

* Send registration forms and payments to Bayer Heritage Federal Credit Union, Attn: Charlene Goddard, 17612 Energy Road, Proctor, WV 26055.

Name
First Last
Address of Participant

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Email *
*We will email you when your t-shirt is available for pick-up (pre-registered only)
Parent or Guardian Name (IF under 18)
First Last
Contact Phone #
### - ### - ####
T-shirt Size
Preferred Location to pick-up t-shirt packet *
* Pre-registered participants only
In Case of Emergency Contact (Name and Ph. #)
Waiver
In consideration of acceptance of this application to participate in the “Miracle Focused, Color Driven” 5k Run and Walk, to be held in Moundsville, WV, on August 22, 2015, I waive myself, my heirs, and assign, all rights and claims for damages which I might have against Bayer Heritage Federal Credit Union, Grand Vue Park, and all other individuals and organizations associated with this race for all injuries which may result from my participation. I attest and verify that I have full knowledge of the risk involved in these events and am physically fit and sufficiently trained to participate. I have read the above statement, I understand it, and my signature confirms its full acceptance. I, also, release my name and any photos of myself to be posted on the internet.
Signature of Participant/Parent or Guardian Signature if Under 18
Clear
Use mouse as a pen to create signature
Date of Signature
MM / DD / YYYY