tt Oty tle Violence’ Wallca-Thon’ Registration Form (Team information and individual participant) Downloadable form Annual Walk-A-Thon in Support of Families who are Experiencing Domestic Violence in our communit Sponsored by Jericho Road Inc, Domestic Violence Task Force Participant Information Name: Age: (IFunder 18 please have your parent/guardian sign the waiver below) Mailing Addre City/State/Zip: E-Mail ‘Team Information (If applicable) Team Name:__ Team JoJo Registration Fee and Deadlines In order to be eligible for a free T-shirt and other prizes the Registration/Liability Waiver, $10 registration fee and a minimum of $20 in donations ($30 minimum total) must be tured in by October 16, 2010 to Jeticho Road INC. P,O.Box 080213 Brooklyn NY 11208. € Ihave included my $10 registration fee € [have included my personal donation of $20 to be eligible great prizes € have included a pledge/donation form along with donations collected totaling $, so I will be eligible for great prizes. € cannot participate but please accept my tax deductible donation of S € See attached Credit Card Authorization Form(If needed) Shirt Order My shirt sizeissS ML LG XL XXL 3X1 (Please Circle one)