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HDSA is a 501(c)(3) nonprofit organization. Federal Tax ID Number (EIN) 133349872. Your contribution is tax deductible to the full extent of the law. West Michigan Team Hope Walk & 5K Offline Registration Form Main Contact Name: __________________________________________________ Team/Company Name: ____________________________________________ Address: _______________________________________________________ City: _________________________________ State: ____________ Zip: _______________ Phone Number: ___________________________________ Email Address: _________________________________________________________________________ Pricing and registration options are listed below. Please enter your personal participation information below and any additional friends or family members you would like to register, each on their own separate row: Participant Name 5K Walk/ Run $20 Fun Walk (1.5 miles) $10 Child for 5K (012 yrs) Free Child for Fun Walk (012 yrs) Free TShirt Size (XSXXXL) Incuded Upgrade Cotton Tshirt to Running Tech Shirt $15 Total 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Additional Donation (optional) Grand Total Payment Information: Please make checks payable to “HDSA” or pay via credit card: Credit Card: Visa/MasterCard/Amex/Disc (Circle One) Name on Card: _____________________________________________________ Number: ____________________________________________________________ Exp Date: _______________________________ CVV: _____________________ Signature: __________________________________________________________ Please mail completed form & payment to: HDSA 267 W 16 th Street Holland, MI 49423 Questions? Interested in volunteering or donating to the raffle? Contact Chelsea Rink at [email protected] or 2693703997 Online registration at: www.hdsa.org/thwwestmichigan
