Name: ___________________________________________________________________
Address: ________________________________________________________________
City: ______________________________ State: _______ Zip: ____________
Age on 10/13: _______ Date of birth: ___________________ Sex: _______
Phone number: ___________________________________________________________
E-mail address: _________________________________________________________
Event? 5K 1 mi. SVR member? Y N WHS member? Y N
(circle one) (circle one) (circle one)
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WAIVER: By signing this race application/waiver, I release the Warren Heritage Society, the Shenandoah Valley Runners, and the race organizers of any liability associated with the Festival of Leaves 5K/1 Mile Family Fun Run/Walk, and I certify that I am in good enough health to the best of my knowledge to safely participate in this event.
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SIGNATURE: _________________________________ DATE: _____________________
Parent or guardian's signature if entrant is under 18:
SIGNATURE: _________________________________ DATE: _____________________ |
Please mail your completed entry form (along with a check payable to "Warren Heritage Society") to: Patrick Farris, Warren Heritage Society, 101 Chester Street, Front Royal, VA 22630-3322.
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