Walk A Mile in Her Shoes Registration

1. Registrant Information

Mississippi Coalition Against Sexual Assault
Walk A Mile in Her Shoes
Sexual Assault and Prevention Awareness Event
Saturday, May 27, 2017 at 8:00 a.m.
Mississippi State Capitol
Jackson, MS

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* 1. General Information

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email: *

Phone Number: *

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* 2. What is your gender?

Female

Male

Each walker is encouraged to dress in RED and wear Red high heel shoes (optional) and asked to make a tax-deductible donation of $10 (Individual); $40 (team of 4) to help the MS Coalition Against Sexual Assault continue efforts to bring awareness and prevent sexual violence in our communities.

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* 3. I am participating at my own risk and release all involved from liability.

Yes

Registration fee is $10 each, Individuals or Teams can participate.

I, the participant, waive and release any and all rights and claim for damages I may have against MS Coalition Against Sexual Assault or other sponsoring organizations and their personnel for any injuries suffered in this event.

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* 4. By entering the Date this is notification of agreement for registration.

Date / Time

Date

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* 5. Click here to make payment by PayPal

(Click here if payment successful)