REGISTRATION FORM

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)
 
$25.00 Adult Ticket/Qty $75 Family Pack/Qty
$20 Kids Ticket/Qty Please contact me.  I would like to start a team.
$15 Kids Ticket(If purchased by April 18)/Qty Please contact me.  I am interested in participating in the 'Celebrity Relay Race For A Cure'®
   
  T-Shirts are included with registration fee.  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 $
Please contact me as soon as possible regarding this matter. 

Please make all check(s) payable to BrittiCares International c/o Brittiana "Smile For Life" 5k, P.O. Box 43504 Los Angeles, CA 90043.  If you need to make changes, or give additional information, please contact us at 323-292-8527.  Please send this form in with your payment.                                         Thank you for your support.
 

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