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Run/Walk/Scoot-a-thon Participant Registration
When: Tuesday, May 7, 2024 3:30-7:30pm
Where: 215 Chestnut St. Dunnville, ON, N1A 2H2
Contact us at (905) 774-6233 or
info@dunnvilleyouthimpact.com
Website:
www.youthimpactcentre.com
* Every participant must fill in their own form *
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* Indicates required question
Name (First & Last)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Address
*
Your answer
Home Phone
*
Your answer
Email
*
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Relationship to Participant
*
Your answer
Emergency Contact Phone #
*
Your answer
I will be:
*
Running
Walking
Scootering
T-shirt Size (Unisex)
*
Adult XS
Adult S
Adult M
Adult L
Adult XL
Adult XXL
Adult XXXL
Youth XS
Youth S
Youth M
Youth L
Youth XL
Required
I understand that I will have to pay $10 to register. If this is a problem, reach out to us and we will help you.
*
Yes, I will e-transfer
youthimpact@rogers.com
(Please include name of registrant in description and specify the amount is for registration).
Yes, I will bring cash.
I will contact you (905) 774-6233 or
info@dunnvillyouthimpact.com
Required
Do you give The Dunnville Youth Impact Centre permission to display pictures of your child or samples of your child's artwork (for example, on the YIC Website, Newsletter, etc)
*
Yes
No
I would like to get a pledge form to raise more money for the Centre.
*
Yes, I would like a digital copy of the pledge form sent to my email.
Yes, I will pick it up from the Centre.
Required
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