Download - Race Application.pdf
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!!
!2015%APPLICATION%
Event:!July!3,!2015!|!Event!Begins!at!6:00!PM!!
Primary!Contact!Name:!!!!!!!!!!!_________________________________________________!
Please!Circle!a!Gender:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!MALE%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%FEMALE!
Mailing!Address!(street):!!!!!!!!!_________________________________________________!
City,!State,!Zip:!!!!!!!!!!!!!!!!!!!!!!!!!!!_________________________________________________!
Cell!Phone:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!_________________________________________________!
Business/Home!Phone:!!!!!!!!!!!!_________________________________________________!
Email:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!_________________________________________________!
Please!Circle!an!Entry!Type:!!!!!!!!!!!!!!!!!!!!!!!!!RUN%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%WALK%
If!Running,!Please!Circle!an!Age!Division!Below:!
%%%%%%%%%%%%%%%%%%Under%20%%%%%%%%%%%%%20924%%%%%%%%%%%%%%%25929%%%%%%%%%%%%%%%%30934%%%%%%%%%%%%%%%%35939%%%%%%%%%%%%%
%%%40944%%%%%%%%%%%%%%%%%%45949%%%%%%%%%%%%%%%%50954%%%%%%%%%%%%%%%%55959%%%%%%%%%%%%%%%%60970%%%%%%%%%%%%%%%%%%75%and%above!!!
!
ENTRY%PRICES%Entry%Returned%by%May%15:%$15%Entry%Returned%by%June%15:%$20%
Entry%Returned%from%June%16%to%Same%Day%Entry:%$25%%
MAIL%APPLICATION%WITH%CHECK%TO:%Firecracker!5K!Run/Walk!
406!Capitol!Street!Charleston,!West!Virginia!25301!
Make!check!payable!to!Childhood!Language!Center!!!
Primary!Contact!Signature:!__________________________________________________!!!!!!!!!!