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Haven in the Hardwood 5k Run & Walk Entry

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Haven in the Hardwood
5k Run and Walk
March 17, 2012

Name:_____________________________Address:________________________

City_____________________State______ ZIP_______Phone____________

Run_____      OR      Walk_____          Female_____    OR          Male_____

Age on  3/17/2012___________

T-Shirt size: S_____  M______ L_____ XL_____

T shirts are guaranteed to all who pre-register!

Pre-registration fee $10 post marked March 9, 2012        _________________

After March 9 and Race Day registration fee $13            ___________________

WAIVER:
For and in consideration of my participation in the Haven in the Hardwood 5K in Pickens, WV, I release the sponsors, the program, its members, volunteers, co-sponsors, landowners and other participants from any claim for injury or loss that occurs to me or my child/ward or anyone on his or her behalf. I therefore attest and verify that I am physically fit and have sufficiently trained for this event.

Please make checks payable to: Pickens Improvement & Historical Society, PIHS

Mail to:
Haven in the Hardwood 5K
PO Box 94
Pickens, WV 26230

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