PLEASE PRINT IN BLOCK LETTERS

REGISTER FOR

(Register online at w w w.firecracker10k.org) 5K Fun Walk Kiddie Run Bike Ride (Sat, Feb 11) (Age 12 & under) I will enter both the race and bike ride, and have included an additional $20 for the second event.

5K Run

10K Run

I will enter both 5 and 10K events and have included an additional $10 for the event bib and be timed for both events. Last Name First Name Street Address Apt. No. State Phone E-mail Age
AGE DIVISION

Middle Initial

City Zip

I have entered Firecracker Run/Bike Ride (circle one event) times.

Sex: Under 10 45-49

Male

Female 10-14 50-54

How I heard about the Firecracker Run: 15-19 55-59 20-24 60-64 25-29 65-69 30-34 70-74 35-39 75-79 40-44 80+

T-SHIRT SIZE Child Medium Large Adult

ADDITIONAL SHIRTS (pre-order only) Small Adult XLarge Adult Medium Adult X XLarge* Adult Short Sleeve T-Shirt Size: Long Sleeve T-Shirt Size: Hooded Sweatshirt Size: $15 ea. $20 ea. $25 ea.

BIKE JERSEY (Must pre-order by Nov. 30, 2011, visit voler.com for size info.) Size: $70 ea.

ENTRY FEE Run/ Walk entry w/ t-shirt *Run/ Walk entry w/X XL t-shirt Kiddie Run entry w/ t-shirt Group of 10+ (must submit entries together before 2/8) Bike Ride entry w/ t-shirt (Sat, Feb 11) *Bike Ride entry w/X XL t-shirt PAYMENT (No refunds - Events go on, rain or shine) Return completed registration form and check payable to: L ACFRC, Inc. (do not send cash)

Early Bird to 10/31

$28 $30 $10 $280 $28 $30

Regular 11/1 - 1/15

$33 $35 $10 $300 $33 $35

Late 1/16 - 2/8

$38 $40 $15 $350 $38 $40

On-site 2/11 - 2/12

$40 $42 $15 N/A $40 $42 *5/10K run and Bike Ride finishers will receive a beautiful commemorative medal

L.A. Chinatown Firecracker Run Committee, Inc.

P.O. Box 86132 Los Angeles, CA 90086

Total Enclosed: $
I would like to donate: $

Waiver: In consideration of your accepting my entry, I intend to be legally bound, do hereby myself, executors, and administrators waive, release and discharge any and all rights and claims for damages which I may have, or which may hereafter occur to me against the L.A. Chinatown Firecracker Race Committee, its volunteers, the City of Los Angeles and other sponsors and contributors, the persons, or organizations affiliated, their representatives, successors and assigns for any and all injuries suffered by me while participating in the L.A. Chinatown Firecracker Run, Walk, Bike Ride events. I will additionally permit free use of my name and pictures in broadcasts, television, print material, etc. I attest and verify I am physically fit and sufficiently trained for this event.

Signature of Runner/Parent for Children Under 18 Years of Age

Date

If participant is under 18 years of age, this certifies that my son/daughter has permission to participate and that event officials can authorize emergency treatment if necessary.