CAROLINA CHALLENGE REGISTRATION
Please provide the following contact information:
Name Street Address City State Zip Code Phone E-mail Home Phone Cell Phone Birthday month 1 2 3 4 5 6 7 8 9 10 11 12 day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year T-Shirt size small medium large x-large Gender Male Female I will be submitting names for the Letter Writing Campaign Yes No
Name
Street Address
City
State
Zip Code
Phone
E-mail
Home Phone
Cell Phone
Birthday
T-Shirt size
Gender
Please list any dietary/medical needs you will have during Carolina Challenge:
Are you dancing with an organization or group? If yes, list organization:
Emergency INFO:
Contact Name: Contact Phone:
Contact Address:
Dancer INFO:
Favorite Song #1 :
Favorite Song #2 :
I fully agree to participate and abide by the rules set forth for Carolina Challenge 2008. I take responsibility for myself and my actions throughout the marathon, and will not hold Bethlehem Center accountable for any injury or any lost or stolen property. In addition, I agree to pay a $25 registration fee and pledge to raise a minimum of $100.00 for Bethlehem Center of Charlotte or submit 10 names and addresses through www.bethlehemcenter.org/letterwriting.asp.
Signature: Date:
Yes, you may use photographs and/or video of me throughout the event for promotional purposes later.
No, you may not use photographs and/or video of me throughout the event for promotional purposes later.
I will: Pay online Mail my check
Once you have clicked submit you will be taken to a secure payment page.
2705 Baltimore Avenue, Charlotte, NC 28203 - Phone: 704.375.1417 - Fax: 704.371.7432 - Contact Us - Site By: EyeBenders
