<p> Run for Prevention of Diabetes 5K Walk and Run</p><p>September 24, 2011 Barboursville Park, Barboursville, WV @ 9 am Registration begins @ 8:30 am</p><p>Pre-registration is $12.00 and will be accepted until Sept. 17, 2011 After Sept. 17, registration will be $15.00. Prizes will be given for overall winners and age groups.</p><p>Name: ______Street Address ______</p><p>City______State ______Zip ______</p><p>Gender : M or F Age ______Shirt size ______</p><p>If you are on an HIMG or ST. Mary’s Team, please provide your department below: </p><p>______</p><p>Disclaimer: In consideration of your accepting this entry, I, the undersigned, intending to be legally bound, declare myself, my heirs, executors, administrators and assignees waive and release any and all rights and claims for damages I may have against the Village of Barboursville, HIMG, Medtronics, Life Scan and the Barboursville Rotary Club and/or sponsors of this event, their officers, directors, agents, employees and any representative thereof , for any and all injuries suffered by me in this event. </p><p>Signature______</p><p>If under age of 18, parent or guardian must sign.</p><p>All proceeds will go to the American Diabetes Association</p><p>Please make checks payable to Mountain State Wellness 5170 Route 60 East Huntington, WV 25705</p><p> c/o Patty Dickey </p>