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Lekotek Run 2008 Registration Form 
(One form per person.  Please copy as needed.)

Name: ________________________________________________________

Address: ______________________________________________________

City: ___________________________    State: _____  Zip: ____________

Age on 9/6/08: __________    Sex: _____ 

Phone: ______________________________

Email: __________________________________________________

Event (check one):
___ 1 Mile Fun Run/Walk 
___ 4 Mile Run

Phantom Runner:   ___ (Unable to attend, but there in spirit.  Please send T-shirt.)

T-shirt Size (circle):   Adult:  S   M   L   XL          Child:  S  M   L

Entry Fees for Run: 
$15.00 by September 2; $18.00 after September 2 and on Race Day. Children under 12 pay dollar amount of their age.  Please make checks payable to Lekotek of Georgia.

Send registration and check to:
Lekotek of Georgia, Inc.
Suite 102
1955 Cliff Valley Way
Atlanta, GA 30329

Entry Fee: $___________

Donation to Lekotek: $_____________

Total of Check: $________________
  

Release

In consideration of being allowed to participate, I, intending to be legally bound for myself, my heirs, executors, and administrators, do hereby release and discharge from any and all, liability for injuries, illness and damages I may suffer arising out of or resulting from my participation in or traveling to or from this event the following: Lekotek of Georgia, Inc. I also hereby release all property owners and persons connected to this event. I further attest that I am physically fit and have sufficiently trained for this event. I understand that my fee is nonrefundable. I hereby certify that I am eighteen (18) years of age, or that I have the consent of my parent/guardian as attested by their signature below.

Signature:  ________________________________________________

                ________________________________________________
                Parent/Guardian (if entrant is under 18)

Date: ___________________