Walk a Mile Individual Registration Form

Registrant Last Name 
Registrant First Name 
Team Name (if applicable) 
Registrant Gender 
Do you need a shoe rental? Note: Only men walkers are requested to wear heels.  
If you need a shoe rental, please list size here. Note: shoes are in men`s sizes 
Only men walkers receive a free t-shirt. Enter t-shirt size here. 
Women walkers: list shirt size and quantity here if ordering online. Add $10 for each shirt ordered to your purchase total below. 
Email Address 
Street Address 
City 
State 
Zipcode 
Phone Number 
 

For payment amount below, registration is $30 for men, $10 for women. Please enter TOTAL payment below.

Payment Information (* Required Fields) 
Payment Description  Walk a Mile Registration
* Payment Amount 
First Name on Credit Card 
Last Name on Credit Card 
Billing Street Address 
Billing Zip Code 
Email 
Card Number 
Card CVV Code (3 or 4 digits) 
Card Expiration (ex 09/2013) 


Registration Fee:
$30 - Men
$10 - Women
Children 12 and under are free and do not require registration
Registration will also be available the morning of the walk but shoe rental will not be guaranteed.

ONLY REGISTRATIONS BEFORE APRIL 1, 2012 ARE GUARENTEED SHOE RENTALS IN THEIR SIZE

 

 

 

 

 

 

Walk a Mile in Her Shoes
The International Men's March to Stop Rape, Sexual Assault & Gender Violence
Visit
www.walkamileinhershoes.org to learn more about the international movement.  

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Partnership for Families, Children and Adults
1800 McCallie Ave. · Chattanooga, TN 37404
Tel: 423.755.2822 · Fax: 423.697.3812
Email: info@partnershipfca.com