You are on page 1of 1

3rd Annual 2013 Michael J.

Buras Memorial Run 5K and Fun Run REGISTRATION FORM Saturday, March 16, 2013 at 8:00am
(Print & mail with check to IGT Foundation, 243 Meadowlark Lane, Fitzgerald, GA 31750; email-igtfoundation@yahoo.com)

Name: _______________________

Gender:__Male __Female

Address: _______________________ Age on day of race ______ City: ___________________________State: ____ Zip: _______ E-mail Address: ______________________________________________
I will participate in the following event: ___5K run ___1-mile Fun Run/Walk ___T-shirt only ENTRY FEES (Due postmarked by March 1, 2013): $15 adult or child_____ additional donation $______ Please check preferred t-shirt size. Adult t-shirt: S M L XL Youth t-shirt: YS YM YL

Make checks payable to: IGT Foundation

XXL

XXXL

Registration 7 a.m. Race Day: $20_____(t-shirt may not be available) .. WAIVER:


In consideration of your acceptance of this entry, I, the undersigned, intending to be legally bound for myself, my heirs, executors, and administrators, do here by waive and release all rights and claims for damages I may have against IGT Foundation and any and all sponsors and officials of this race from any liability arising from illness, injuries, and damages I may suffer as a result of my participation in this event. I attest and verify that I am physically fit and have sufficiently trained for this event. I give my permission for the use of my picture and name in any media coverage in this event.

Signature____________________________________ Guardian signature required if under age __________________________________


For Official Use Only: Payment rcvd t-shirt rcvd

Date_____________ Telephone # _________________


runner bib #