WALK 4 LITE REGISTRATION
Last Name:
*
First Name:
*
Mailing Address:
*
City:
*
State:
*
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code:
*
Date of Birth:
Phone:
*
E-mail:
*
I would like to contacte to volunteer for the 5K
Yes
No
5K Walk/Run T-Shirt
Small
Medium
Large
X-Large
XX-Large
XXX-Large
Event - 5K
(1.9 miles)
Run
Walk
Age Division:
Men
18 & Under
19-29
30-39
40-49
50-59
60+
Women
18 & Under
19-29
30-39
40-49
50-59
60+
I here by declare myself in good physical condition and able to run or walk in The Butterfly Movement Walk 4 Lite event. I do hereby waive and release the individuals associated with this event, its agencies, representatives, successors, and assigns, from any claims for damages of any nature, including personal injury that I may incur as a result of my participation.
Signature:
*typed signature will be used as official acknowledgement
Please Retype Verification Word
*
Registration Fee
Adult Fee ($
25
)
Child Fee (12 and Under) ($
5
)
Late Registration (After March 31st) ($
30
)
Total : $
0