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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: ___________________