Walking Club/Individual Registration Form

Please circle  Walking Club   or    Individual

Walking Club Section

Name of Walking Club: ________________________________________  Total Walkers: _____________

Contact Person Name: __________________________________________________________________

Individual Section

Gender: ___________    Race: __________     Age: _________     Height: _________      Weight: ________

Address: _____________________________________________________________________________

City: ____________________________  State: _______   Zip Code: ___________  County ____________

Phone: __________________   Other Phone:  ___________________  Cell Phone: ___________________

Email: _________________________________  Other Email: ___________________________________

Please return your mail-in Registration Form to:

Project FACT