St. Vincent De Paul Mission Registration 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

RACE – Secure Online Registration Form

Each person in the 5K race must fill out this form individually (by a parent if registering a child under 18). Persons under 18 participating in this event must be accompanied by a responsible adult. (Note: This form is for the race only; there is a different form for walkers and volunteers.)

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: Race - $25, $30 if after October 19

*Please select your Team Name from the list below:

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

*I agree to abide by the rules of the Walk in their footsteps – Race for awareness event
and comply with the directions given by event leaders.

Donors and Sponsors, please select the “N/A” option

*I 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:  *Email: 
*Phone *Emergency Contact: 

            *T-Shirt Size:  *Age on Race day:  *Sex: 

Donor Sponsoring: 

*Registration Fee Race - $25 by October 19, $30 thereafter .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 or call 203-754-0000

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