Individual Registration Form

June 12, 2010 – June 15, 2010

General Information
First Name:_______________________ Last Name:________________________
Phone number:______________________________________________________
Address:____________________________________________________________
City:______________________________ State:_______ Zip Code: ___________
Email Address: ______________________________________________________
Age: ______ **If younger than 18, please complete the Parent Guardian waiver, in
addition to the Accident Waiver and Release from Liability Form

Parents Email Address ( if younger than 18)_____________________________________

Parents Phone Number (if younger than 18)____________________________________

How long will you “march” with us:

The full March, 80miles, 4days Half the March, 40 miles, 2 days

One day of the March. Please let us know which day

you will join us______________________

Emergency Contact Information

First Name:_______________________ Last Name:________________________
Phone number:____________________ Cell: _____________________________
First Name:_______________________ Last Name:________________________
Phone number:____________________ Cell: _____________________________
Please complete this form along with the Accident Waiver and Release from Liability Form and
return to Mac McStravick at 1201 Austin Street; Richmond, TX; 77469. For additional
information please contact Mac at mmcstravick@ces-richmond.org or 281-857-4038 or 281-
342-3161