The Katy Bug Shuffle

REGISTRATION FORM

 

NAME__________________________________________ AGE_________

 

 

MALE               FEMALE                         PHONE_______________________

 

ADDRESS____________________________________________________

 

CITY/STATE/ZIP______________________________________________

 

EMAIL_______________________________________________________

 

EMERGENCY CONTACT_______________________________________

 

EMERGENCY PHONE #________________________________________

 

TEAM NAME & CAPTAIN______________________________________

 

Make Checks payable to: The Katybug Shuffle

 

	On or before July 31	Aug 1- Sept 28	Sept 29 - Race Day
5K	$25	$30	$35
Team ≥ 10 (per person)	$20	$25	$30
Kids’ Fun Run	$10	$15	$15

 

T-Shirt Size: YS ____      YM ____      YL ____       S ____

 

                          M ____          L ____       XL ____       XXL ____

 

WAIVER AND RELEASE STATEMENT  (All participants must read and sign)

I have read the accompanying event information and understand the policies of the event. I know that running and walking a trail race is a potentially hazardous activity. I should not enter unless I am medically able and properly trained. I assume all risks associated with my voluntary participation in this event, including but not limited to, falls, contact with other participants, the effects of the weather, including extreme temperatures, traffic and all conditions of the road, all such risks being known and appreciated by me. Knowing these facts, and in consideration of your accepting my entry, I for myself, my heirs, executors, administrators, or anyone else who might claim on my behalf, covenant not to sue and WAIVE, RELEASE AND DISCHARGE Pottsboro ISD, City of Pottsboro, Hagerman Wildlife Refuge, Grayson County, The Katybug Shuffle 5K Committee, all sponsors, race officials, workers or volunteers, their representatives, successors or assigns for ANY AND ALL claims or liability, whether foreseen or unforeseen, for death, personal injury or property damage arising out of , or in the course of my participation in this event. I further grant full permission to the above mentioned sponsors, organizers, and/or agent authorized by them, to use any photographs, videotapes, motion pictures, recordings, or other record of the event for any reasonable purpose including but not limited to use of photos, videos, etc. in promotion of this year’s event and all subsequent events.

 

________________________________________________________________________

Printed Name of Participant  (or Parent/Guardian if entrant is age 17 or under)

 

 

________________________________________________________________________

Signature of Participant                                                                                  Date

(Or signature of Parent/Guardian if entrant is age 17 or under)

 

Mail nonrefundable fee & registration form to:

 

The Katybug Shuffle 5K

P.O. Box1437

Sherman, TX 75091

 

October 6, 2012

Registration begins at                 8:00 a.m.

Kids’ Fun Run at            8:30 a.m.

                               5K at            9:00 a.m.

 

 

 

Starting Line at

Pottsboro High School

901 E. FM 120, Pottsboro, TX

 

Course Info

 

The race will begin at Pottsboro High School and travel 1.55 miles down Katy Lane to a turn around point and come back to the high school. The Koop’s Kids’ Run will be approximately one mile around the school.

 

Registration

 

Fill out the form in this brochure and mail to the address provided. Please mail by September 28^th   to ensure receipt. You can also register online.

 

Teams of 10 or more will receive a discount of $5 off the registration fee.  Please complete one registration form for each member and mail with payment in one envelope.  After a team registration has been turned in, members may not be added to the team.

 

Packet Pickup

 

Packets will be available Thursday, October 4^th  from 4:00-6:30 p.m. at Friendship Park at 615 Hwy 120 East in Pottsboro. They will also be available race day from 8:00-8:30 a.m.

 

T-Shirts

 

All entrants who register on or before September 24^th will be guaranteed to receive an event t-shirt. Entrants after this date will receive a t-shirt as long as supplies last.

 

Awards

 

Medals for the 5K will be awarded to the top three male and female runners in each age group and also to the overall fastest male and female. All registrants in the Koop’s Kids’ Run will receive a kids’ medal.

About Katy

 

Katy is a vibrant six year old who is battling leukemia.  She was diagnosed in August 2010 with High Risk Pre-curser B Acute Lymphoblastic Leukemia.  Though she is currently in remission, Katy will remain in active treatment until December 2012.  At that point, she will continue visits with her oncologist for the months and years to come.

 

In addition to monthly visits to her oncologist in Dallas, Katy has been hospitalized several times in the past year due to fevers and neutropenia (low blood counts).  Visits to the emergency room have been frequent since her immune system remains compromised.  She remains at a greater risk for infections.  Because of this, she was also placed on homebound for three months of the school year to curtail illness.

 

In May 2012, Katy had surgery to replace her port-a-cath, which is how she receives her chemotherapy.  Her previous port became ineffective due to a fibrin sheath that developed on the tubing.

 

The family’s medical bills continue to mount due to Katy’s ongoing care.

 

Contact Us

 

If you would like to sponsor this event, volunteer, or need additional information, please contact us at katybugshuffle@yahoo.com

 

For more information visit our website at katybugshuffle.shutterfly.com

 

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