!!

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