Saturday, May 5, 2007 -- Lewisburg, WV
Hospicecare 10K Run (iPO Event Id#: 10071)

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I, the undersigned, hereby enter the above-described race. In consideration of the acceptance of my entry, I certify that I am physically fit to participate and agree to be bound by all the rules of the event and decisions of the official judges. I do hereby forever release and discharge the sponsors of the event, HospiceCare and Greenbrier Valley Road Runners and all other officers, agents, employees and directors of said organizations from any and all claims, causes of action or suits in which I, or my heirs or assigns, shall or may have arising from a result of my participation in the said event to be held May 05, 2007. I do further consent to the use of my name and/or photographs in connection with publicity concerning the race.

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Last Name: _____________________________ First Name:  _______________________

Middle Initial:_________    

Address: ___________________________________________________________________ 

City: ______________________________________State: __________Zip: ____________    
       

Phone No.: ________________Age: ______  Male/Female     T-Shirt Size: M    L    XL
                 (circle one)             

Signature____________________________________________________Date:_________
(Signature of Participant or Guardian if under 18 years of age)

EMAIL_______________________________________________

Mail entry form & fee to: Lee Scruggs Greenbrier Valley Medical Center - P.O.Box 497, 202 Maplewood Ave Ronceverte WV 24970