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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:!__________________________________________________!!!!!!!!!!


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