In Their Shoes Walker Registration

We're excited you plan to join us for the In Their Shoes Walk!
* Indicates required information
Walker Name (First and Last) *
Team Name (If on a Team)
E-mail Address
Street Address 1 *
Street Address 2
City *
State *
Zip *
Home Phone Number *
Cell Phone Number
Date of Birth *	(mm/dd/yyyy)
Gender *	Female Male
T-Shirt Size	Small Medium Large XL XXL XXXL
Are you a cancer survivor?	Yes No
Are you interested in becoming a walk training coach?	Yes No
Are you willing to share your contact information with other participants? *	Yes No
How did you hear about the walk? *	Friend/Relative Brochure Newspaper TV or Radio
Emergency Contact Name *
Emergency Contact Relationship *
Emergency Contact Phone *
Second Emergency Contact Phone *
Your Allergies (Food, Medication, Environment, etc.)
Do you acknowledge your personal commitment to raise a minimum of $1,000 ($900 for a team of 5 or more)? *	Yes
The Registration Fee is $50 (applied to $1,000 minimum). You can pay online with Visa or MasterCard. *
If you'd like to add an additional donation, please enter the amount here.
Card Number *
Name on Card *
Expiration Date *	Month Year
Security Code (on back of card) *
I hereby release this information to the In Their Shoes walk medical team and any other medical personnel, hospital personnel, etc., who may need to care for me during the walk. *	I Agree
By submitting this application, I assume all risks and dangers incidental to the walk and release the In Their Shoes walk, its sponsors, participants and all agents from any and all liabilities resulting from any and all activity associated with the walk. *	I Agree