Registration for the Rockford Walk
Team Name: *
Your answer
Names of Team Members: *
Your answer
Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Phone Number: *
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Email Address: *
Your answer
Select the number of t-shirts your team will need. Each shirt will need a minimum of $10 pledge.
small: *
medium: *
Large: *
XL: *
XXL: *
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This form was created inside of Epilepsy Foundation North Central Illinois.