Walk a Mile Registration

First Name: *

Last Name: *

Name of Organization: *

Home or Work Address: *

City: *

State: *

Zip Code: *

Primary Phone Number: *

Alternate Phone Number:

Email Address: *

T-Shirt Size: *

Team Name:

NOTE: Sexual Trauma Services of the Midlands reserves the right to change any team name that is deemed inappropriate or offensive to participants (including names involving profanity or of a sexually implicit nature). Please use proper judgment when selecting names and artwork, our goal is a fun, pleasant atmosphere for everyone involved.
Pre-Registration date begins April 4th - Limited t-shirts available for late registration.

Event Registration: *

Walk a Mile in Her Shoes SAAM, Wednesday, April 14, 2010 6:00 PM, Five Points, Columbia, SC $10 if you pre-register, and $15 if you pay at the event (t-shirt included in registration fee)

Completed applications must be submitted online or returned via email, mail or fax to Sexual Trauma Services of the Midlands. If registering by email or fax, you will receive a confirmation of registration by email with a link to the agency’s Donate Now page, where you can pay. If paying by mail, please include your payment with the registration form. Your registration is not complete until payment has been received by STSM.

Fax #: 803-790-8282

Email: stsm@stsm.org

Mail: STSM, 3700 Forest Drive, Suite 350, Columbia, SC 29204

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