Count me in, I’m WALKING!
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Your Name*

Your Street Address*

Your City*

Your State* Your Zip Code*

Your Phone*

Your Email*

Your Church/Group

My goal is to raise $

Age Group:  Adult  Teen Child

Have you walked in a Walk For Life before?  Yes No

Please send me additional brochures to distribute at work, church or school.

Shirt Size needed (check one):

Youth:  S M L

Adult:  S M L XL