Blue Cross and Blue Shield of Texas presents the Speak Up For Kids CASA 5K & Kids K Fun

Run Series. Proceeds from this race go directly to CASA of Deep East Texas
Our Mission: CASA of Deep East Texas trains and supervises volunteers to speak in court for abused and neglected foster care children.
Please use one registration form per person or register online at www.casa5k.org. Call (936) 564-9711 for more information.

PRE-REGISTRATION LATE REGISTRATION

Date: November 7, 2009
Ends October 18, 12:00 a.m. Ends November 1, 8:00 a.m.
Location: Pecan Acres Park

Race Time: Kids K - 9:00 am | 5K - 9:30 am MAKE CHECKS PAYABLE TO: MAIL ENTRY FORM TO:
CASA of Deep East Texas 422 East Main Box 243
Pricing: Kids K - Early Registration: $10 / Onsite: $15 Nacogdoches, TX 75961
5K - Early Registration: $20 / Onsite: $25
Groups of 10 or more: $15 per entry

LAST NAME: ________________________________ FIRST NAME: ________________________________ AGE: __________ SEX:_______

ADDRESS: __________________________________________________________________ CITY: _____________________________ STATE: ______________ ZIP: _______________

DAY PHONE: (_______)____________________ HOME PHONE: (_______)____________________ EMAIL:____________________________________________________________

SHIRT SIZE (circle one): S M L XL

CHILD SIZE (circle one): YM YL

Check # ___________ Enclosed Total $_____________

WAIVER: In consideration of your acceptance of this entry form, I hereby release the sponsors, officials, owners of the facilities used for this race and any and all groups, people or facilities connected with the CASA Speak Up For
Kids 5K and Kids K for any and all injuries by me at said race. I further certify that I am physically fit to participate in the run. I hereby grant full permission to any and all of the foregoing to use any photographs, videotapes, motion
pictures and recordings or any record of this event.

_____________________________________________________________________________
SIGNATURE

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PARENT’S SIGNATURE (IF 18 AND UNDER)

For Office Use Only

Race Number: ___________________