Regist Form

$Children\'s Svcs$

2nd Annual Walk, Run, Roll & Caring Rally...REGISTER NOW! ! ! ! Due by August 8, 2008.... Minimum Donation $10.00.... Call Melanie for more information at 724-283-3198.

Registration Form

* indicates required fields

*Name:

*Address:

*City:

*State:

*Zip Code:

*Phone Number:

Number Attending:

Events Attending:

Walk Only 10 am - 12 pm
Picnic Only 12 pm - 3 pm
Entire Event

PotLuck Picnic Dish:

I am Unable to attend, but would like to donate $:

Last & First Name:

T-Shirt Size #1:

Child Small
Child Medium
Child Large
Small
Medium
Large
XL
XXL

Last & First Name:

T-Shirt Size #2:

Child Small
Child Medium
Child Large
Small
Medium
Large
XL
XXL

Last & First Name:

T-Shirt Size #3:

Child Small
Child Medium
Child Large
Small
Medium
Large
XL
XXL

Last & First Name:

T-Shirt Size #4:

Child Small
Child Medium
Child Large
XL
XXL

Comments or Questions:

Community Care Connections, Inc. 114 Skyline Drive Butler, PA 16001
Phone: (724) 283-3198 - Fax: (724) 283-5945
www.communitycareconnect.org