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
  


Secure Online Registration Payment Form

This form must be filled out by an adult walker or volunteer
and/or for members of his/her family who may be participating.

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.

Registration Fee: Walk/Staff - $10, under 9, free
Persons under 18 participating in this event must be accompanied by a responsible adult.

*Registering as:  

*Please select your Team Name from the list below:


*Please click here to read the Liability Waiver & Consent Statement.

*I (and my family) agree to abide by the rules of the Walk in their footsteps -- Race for awareness event,
and comply with directions given by Event Leaders.

Donors and Sponsors, please select the "N/A" option.


*I (and my family) agree with the terms of the Liability Waiver & Consent Statement.

Donors and Sponsors, please select the "N/A" option.


*First Name:  *Last Name: 
*Address 1:  Address 2: 
*City:  *State: 
*Zip Code:  *E-mail: 
*Phone (with Area Code) *Emergency Contact: 

     *T-Shirt Size:       *Under 18? 

Family Member #1:  T-Shirt Size:  Age: 
Family Member #2:  T-Shirt Size:  Age: 
Family Member #3:  T-Shirt Size:  Age: 
Family Member #4:  T-Shirt Size:  Age: 
Family Member #5:  T-Shirt Size:  Age: 
Family Member #6:  T-Shirt Size:  Age: 

Donor Sponsoring: 


Please enter the total amount for registered participants:

.00
Additional contribution:
.00
Donation from a friend of St. Vincent DePaul Mission:
.00

Total amount    $  .00


*Credit Card Type: 
*Credit Card #: 
*Exp. Date:  /


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 duplicate charges to your account.
An email confirmation will be sent to the email address you provided.

 


  
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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