West Virginia RoadKill Cookoff Possum Trot 5K Run/Walk
Registration Form
Last Name: ____________________________ First Name: ______________________
Address: ______________________________________________________________
City: ____________________________________ State: _________ Zip: ___________
Phone: ________________________ Email: __________________________________
Emergency Contact: ___________________________ Phone: ____________________
Age: ______ Date of Birth (mm/dd/yy): _____/_____/_____ Gender: ◻Male ◻Female
Age Division (check below)
◻14 & under ◻15-19 ◻20-29 ◻30-39 ◻40-49 ◻50-59 ◻60+
T-Shirt Size (check below)
◻Small ◻Medium ◻Large ◻Extra-Large
Entry Fee Before September 1: $12
After September 1, and race day: $15
Make checks out to: Pocahontas County High School. Please send registration and payment to Kay Wiley at Route 1, Box 43F, Green Bank, WV 24944.
Race begins promptly at 9:30 am, with registration at 8:00. Runners should gather in the City National Bank (300 8th St) parking lot in Marlinton, WV. The course begins and ends on the Greenbrier River Trail, near Route 39.
I know that running a road race is a potentially hazardous activity. I should not enter and run unless I am medically
able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete
the run. I assume all the risks associated with running in this event including, but not limited to: fall, contact with
other participants, the effects of weather, including high heat and/or humidity, traffic and other conditions of the road,
all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in
consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the
Pocahontas County Chamber of Commerce and all sponsors, their representatives and successors from all claims or
liabilities of any kind arising out of my participation in this event. I grant permission in this event to all of the
foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate
purpose. All forms must be signed. Incomplete or unsigned forms will not be accepted.
Signature _________________________________________ Date _______________________
Signature _________________________________________ Date _______________________
Signature of parent/guardian if entrant is under 18
Questions? Please contact Kay Wiley at (304)456-4119.
Return to RoadKill Forms Main Page |
