Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Helen Keller Hospital

Sunset Run 2016

5K & 1 Mile Fun Run - July 29, 2016

Pre-registration must be received by July 25, 2016.

Make checks payable to: Helen Keller Wellcare Center

5K Fee by July 25 - $12.00
After July 25 - $15.00
One Mile Fee - $10.00
Both - $20.00

Download a printable version here.
  Name
  Address
  City/Zip
  Phone
  T-Shirt Size
  Sex Male
Female
  Age on 7/29/2016
  Birthdate (MM/DD/YYYY)
  5K
One Mile
Both
* Cardholder First Name
The first name of the account holder as it appears on the credit card.
* Cardholder Last Name
The last name of the account holder as it appears on the credit card.
* Amount of Payment
Format: 45.67 (Include decimal and cents. Do not use a dollar sign.)		 $
* Card Number
* Expiration Date
* Card Code Verification Number
The three digit number on the back of your card. (Four digit code on the front of American Express.)
* Billing Postal or Street Address
* Billing City
* Billing State
* Billing Zip Code
5 digit zip code

?>