Wednesday, October 18th, 2017 | Login

Events Registration and Payment Form


Participant Information
Name
Email Address
Telephone Number
Tshirt Size
Age
Gender

Billing Information
Type Of Payment
Billing Address

Address Where Your Credit Card Statements Are Mailed.
City State Zip Code

Please Include Your City, State and Five Digit Zip Code.
Release Authorization

In consideration of your accepting this entry, I, the signee, intending to be legally bound, hereby, for myself, my heirs, executors, and administrators, have read the waiver associated with this event and release any and all rights and claims for damages I may have against Elbert Memorial Hospital or their sponsors, hosts, officials, workers, representatives, successors, assigns, for any and all injuries suffered by me in this event.
Click "Submit" to print your form and mail it along with your check.
Or, click "Donate" to pay online with PayPal.


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