Walk a Mile Individual Registration Form

Registrant Last Name
Registrant First Name
Team Name (if applicable)
Registrant Gender	Male Female
Do you need a shoe rental? Note: Only men walkers are requested to wear heels.	Select One Yes No
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)
Please wait. Allow up to 2 minutes for processing. Please do not 'refresh' or go 'back' until the transaction is completed and you have received the success or failure message on your screen.

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.