Registration

Contact Information

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone*

Registration

Quantity
Price
Total
Child 6-12
X
$
5.00=
$
0

Adult
X
$
15.00=
$
0

Student
X
$
10.00=
$
0

Final Total:
$
0
Donate or Keep My T-Shirt *
  • I want a new T-Shirt
  • I already have a Walkathon t-shirt, please donate my new t-shirt to a student.
1st Person's Name
2nd Person's Name
3rd Person's Name
4th Person's Name

*If you need to select more than 4 t-shirt sizes, please write below in "Additional Comments".

Statement of Consent and Liability Clause*
  • I agree to the content of this Statement of Consent and Liability Clause.
I Belong to ... Group/Church (Optional)

Payment Information

Amount*
$
Name on Card*
Card Number*
Additional Comments

Security Code

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