St. Vincent DePaul Mission Secure Online Form
Walk in their footsteps -- Race for awareness
a 2.5 mile walk and 5K race


Sunday, October 22, 2017, 12:00 pm noon Check-in
1:00pm Walk Start; 1:30pm Race Start
  


Team Name Request Form

Please note that fields with an asterisk (*) are required.
For your security, this form will not work if you use the AutoFill feature in your browser.

*Please choose one:   Walk       Race 

 *Team Name:
  

 *Leader First Name:

 *Leader Last Name:

 *Relationship to the team: 
        

This form is used to request a team name only.
The Team Leader and each member of the team also must complete a “Secure Online Registration Form” or the hard copy Participant Registration Form.


 *Please provide the name of the organization sponsoring your team. If not applicable, please type N/A:
  

*Address 1:  Address 2: 
*City/Town:  *State: 
*Zip Code:  *E-mail: 
*Phone (with Area Code):  *Emergency Contact: 


*Approximate number of adults on team:

      *Approximate number of children under age 18 on team:




After ensuring that all of the information above is correct,
please click the Submit Form Now button ONLY ONCE.
Multiple clicks of the Submit button will result in duplicates.

Your Team Name will be available in the registration payment form shortly.



  
St. Vincent DePaul Mission of Waterbury, Inc.
34 Willow Street, P.O. Box 1612
Waterbury, CT 06721
For information: e-mail st.vincent.depaul@snet.net or call 203-754-0000


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