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  If you'd like to walk, then please complete the following registration form. By pre-registering now, you save yourself time on Walk-day and help us get a jump on the huge amount of data entry that needs done for an event like the Walk for Life.

* Required fields
 

    *Name
    *Street address
    *City
    *State/Province
    *Zip/Postal code
    *Country
    *Home Phone
    Work Phone
    Fax
    *E-mail
    Web site URL
    Date of birth
    Gender:
    Male  Female

*Church or Organization affiliation (if none, enter "none"):

*
Church or Organization location (city/state):

I am an/a:

    Adult
    Teen

    Child
How did you hear about the walk?:
    Church
    Mail

    Friend

    Web

    Parent

    Newspaper

    Other: 
Have you walked in the Harbor House WALK FOR LIFE before?:
Yes  No
* "I release Harbor House Maternity Home Inc. from any liability for this event":
Yes  No


We will respond personally to your registration via email once it has been processed, which could take up to 72 hours. Please let us know if you do not receive a confirmation email. Thank you!



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