HDSA is a 501(c)(3) non-‐profit organization. Federal Tax ID Number (EIN) 13-‐3349872. 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
(0-‐12 yrs) -‐-‐-‐-‐-‐-‐-‐-‐ Free
Child for Fun Walk (0-‐12 yrs) -‐-‐-‐-‐-‐-‐-‐-‐ Free
T-‐Shirt Size
(XS-‐XXXL) -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 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 16th Street Holland, MI 49423
Questions? Interested in volunteering or donating to the raffle? Contact Chelsea Rink at [email protected] or 269-‐370-‐3997
Online registration at: www.hdsa.org/thwwestmichigan
