O F F I C I A L ENTRY FORM Please print clearly in ink. One entrant per form. Form may be copied. SATURDAY, MARCH 21, 2015 Name ______________________________________________________________________________________________________________________ Address FIRST LAST ____________________________________________________________________________________________________________________ City ______________________________________ State ______________________________________ Zip _________________________________ Email Address ______________________________________________________________________________________________________________ Phone Day ( _____ ) __________________ Cell Phone ( _____ ) __________________ Age (as of 3/21/15) ______________ Birthdate ______________________ Event ❑ 10K run ❑ I am part of a team ❑ Male ❑ Female ❑ 5K run ❑ 5K walk ❑ Kids K ❑ I want to lead a team Team Name: __________________________________________________________ How did you hear about the Lookin’ Good Shamrock Strut Fun Run? ________________________________________________________ I am unable to participate in the Lookin’ Good Fun Run, but I want to support the Houston Eye Associates Foundation. Enclosed is my tax-deductible donation of $ ____________________ HARRA Members receive a $2 discount. Member # _____________________________ Entry Fees Regular Registration March 1 to March 15, 2015 ): • $22 Kids K (12Fee and (under) 5KEarly and 10K $25 (received Kids K by March 6) • $37$33 Registration Entry Fee $ _________________ — HARRA Discount $ _________________ Moisture-Wick Shirt $ _________________ Late Registration Fee (March 16 to March 21, 2015 • $37 Registration (Received by March 15)): 5KLate and 10K $25 Kids K • $45$45 Registration Total Due $ _________________ (Shirts and Packets are not guaranteed during Late Registration) (shirts and packets are not guaranteed during late registration) T-Shirt Size (Cotton Shirt provided with Registration) Adult ❑ S ❑ M ❑ L *To secure a race shirt, runners must pick up packets during scheduled packet pickups. Moisture-Wick Shirt $15 each Adult ❑ S ❑ M ❑ L ❑ XL Payment ❑ Check payable to: Houston Eye Associates Foundation ❑ Credit Card _____MC _____Visa _____AMEX _____Discover ❑ XL Kids ❑ ❑M ❑L I understand that no refunds will be given and that the event will be held rain or shine. Credit Card # __________________________________ Exp. Date ____________________ CVV Code ____________________ Name on Card _________________________________ Signature ____________________________________________________ Waiver (must be signed to participate) In consideration of acceptiance of this entry, I waive and release any and all claims for myself and my heirs against Gulf Association of USA Track and Field, the City of Houston, the Houston Eye Associates Foundation, all spoonsors of the event and all officials of this race for any injury or illness which may directly or indirectly result from my participation in the Lookin’ Good Shamrock Strut. I further state that I am trained and in proper physical condition to participate. I understand that the entry fee is non-refundable and numbers are non-transferable. If entrant is under 18 years of age, parent or guardian must sign entry. Signature (parent or quardian if under 18) ______________________________________________________ Date ________________________ Mail to: Houston Eye Associates Foundation • 7155 Old Katy Road, Suite N100 • Houston, Texas 77024 Registration is also available online at www. houstoneye.com or call (713) 558-8740. Fax: (713) 395-1666