Genesee County Habitat For Humanity

Present

To Benefit Habitat for Humanity
Saturday, July 19, 2008
7:45 a.m.
Fenton, Michigan

Full Name
(Last) (First) (Middle)

Street City St Zip

Phone Birthday Day Year Age on race day

15K Run and 5K Run/Walk

Shirt Size ML XL XXL (+$2.00)

Sex: Male Female

Event

CHIP Information (Check one of the following) NOTE: All participants must wear a chip to be scored.
I own my ChampionChip. My chip number is
I will be using a rental chip and understand that I will be assessed a $30 fee if I do not turn in my chip at the finish.
I would like to purchase my own ChampionChip.
I have enclosed a check, payable to Gault Race Management, for the purchase amount of $33.00 ($30.00 + tax and shipping)

Total Amount Enclosed Make check payable to: Genesee County Habitat for Humanity

Mail form to: The Bastille Day 15K Run / 5K Run and Walk * Genesee County Habitat for Humanity * G-5191 S. Saginaw * Flint, MI 48507

In consideration of my participation in this event, I for myself, my heirs, executors, and administrators, waive and release all rights and claims for damages I may have against the sponsors of this event, their agents, representatives, successors, and assignees for any and all injuries suffered by me at said run, or which may arise out of my traveling to, participating in, and returning from these events. I further state that I am in proper physical condition to compete in this event.

Athlete or parent signature _________________________________

Date: _____ - _____ - _________