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Lekotek Run 2010 Registration Form 
(One form per person.  Please copy as needed.)

Name: ________________________________________________________

Address: ______________________________________________________

City: ___________________________    State: _____  Zip: ____________

Phone: ___________________________________

Email:  ___________________________________

Age on 8/28/10: __________    Sex: _____ 

Event (check one):
___ 1 Mile Fun Run/Walk 
___ 4 Mile Run
___ Phantom runner (unable to attend; please send T-shirt.)

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

Entry Fees for Run: 
$18 by August 16; $20 after August 16 and on Race Day. Children under 12 pay dollar amount of their age.  Please make checks payable to Lekotek of Georgia.

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 or guardian if entrant is under 18)

Date: ___________________

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