BrittiCares -SMILE FOR LIFE 4TH 5K REGISTRATION FORM

REGISTRATION FORM IS CLOSED

BrittiCares International® is exempt under Section 501 (c) (3) of the Internal Revenue Code, making this gift tax deductible to the extent allowed by law. Federal Tax ID # 55-0887916. Please consult your tax advisor.

PARTICIPANT INFORMATION FOR BRITTIANA "SMILE FOR LIFE" 5K RUN/WALK

Full name:		Company:
Address:
City:		State:		Zip Code:
Country:		Email:
Telephone:		I would like to be added to your e-mail list Yes No

I WOULD LIKE TO REGISTER FOR THE FOLLOWING (please check all that apply)

	COMPETITION RACE 5K-Registration WINNER RECEIVES $CASH PRIZE. $35.00 Platinum Runners 14 & Older/Qty Winner Receives $250.00 - 2nd T-Shirt - 3rd Baseball Cap $25 Gold Runners 13 & Under/Qty Winner Receives $100.00 - 2nd T-Shirt - 3rd Baseball Cap Lunch & complementary raffle ticket incl. with all Competition Race Registrants TIMING & RACE RESULTS BY PRIME TIME Please contact me. I am requesting a pledge form Please contact me. I would like to start a team.		FUN RUN 5K- Registration ALL PARTICIPANTS RECEIVE A RIBBON $25 Adults 18 & older $15.00 Kids 17 & under/incl. lunch & games/Qty FREE Kids 5 & under(lunch & t-shirt not incl./Qty $75 Family Pack/Qty 2 Adults 2 Kids(Does Not apply to Competition Race) food & games included for kids registration FREE Childhood cancer patients/Qty with prior approval only from BrittiCares) A PARTICIPATION WAIVER MUST BE COMPLETED FOR EACH PARTICIPANT Click to download FOR MORE INFORMATION CALL 323-292-8527
	ONLINE REGISTRATION WILL NOT BE AVAILABLE AFTER MONDAY MAY 25, AND A $5.00 ADDITIONAL FEE WILL BE ADDED TO SAME DAY REGISTRANTS.
	T-Shirts are included with registration fees while supplies last. Please indicate sizes and quantity below.
	T-Shirt Sizes & Quantity MEDQty LRGQty XLQty XXLQty
	I AM UNABLE TO ATTEND THE BRITTIANA "SMILE FOR LIFE" 5K. HOWEVER, I WOULD LIKE TO MAKE A DONATION IN THE AMOUNT OF $25 $50 $100 Other $
	I AM ATTENDING THE BRITTIANA "SMILE FOR LIFE" 5K, AND IN ADDITION TO MY REGISTRATION/ENTRY FEE, I WOULD LIKE TO MAKE A DONATION IN THE AMOUNT OF $
	TOTAL AMT INCLUDED FOR REGISTRATION & DONATIONS $

If you would like to register by mail, please attach this form with your payment(mail in payments for registration must be received prior to event date). Please make all check(s) payable to BrittiCares International c/o Brittiana "Smile For Life" 5k, P.O. Box 43504 Los Angeles, CA 90043.