International Crisis Aid

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Thank you for registering to participate in the 5K Run/Walk for Freedom sponsored by LIFECHURCH. Your participation in this event will help raise funds for Crisis Aid's Refuge Homes for victims of trafficking.

We appreciate your commitment to our Refuge Homes and look forward to seeing you on September 26, 2015, at 1416 Larkin Williams Rd, Fenton, MO 63026. Check-in will begin at 8:00am and the Run/Walk will kick off at 9:00am. LIFECHURCH will e-mail you further information as the event approaches, including directions, the meeting location, etc. If you have any questions before then, feel free to contact Crisis Aid at info@crisisaid.org or LIFECHURCH at contact@lifechurch-stl.com.

Qty

Description

Amount

Total

Family Discount

$60.00

up to 4 family members

Additional Adult / Child

$10.00

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Additional Donation

Donation On Behalf of Someone

Total: $60.00

If you made a donation on behalf of someone,
please include name below

On Behalf of Someone:

How many people are in your family? *

(It is not necessary to fill out Participant Information if only making a donation)

Primary Participant Information

First Name:

Last Name:

Date of Birth (for chipped runners):

Team Name:

If you are participating as part of a team, what is your Team Name?

Waiver: *

By checking accept, the participant(s) and/or the company they are participating within the 5K Run for Freedom hereby agrees to indemnify and hold St. Louis County Government, LIFECHURCH, and International Crisis Aid (dba: Crisis Aid International) and their officers, directors and employees hold harmless from any and all claims, damages, costs, attorney fees, etc., associated with or arising out of Participant’s participation during the 5K event, brought against St. Louis County Government, LIFECHURCH, Crisis Aid International or any person or entity holding an interest hereunder as a result of any action taken pursuant to this Agreement.

Type of Run: *

I will be participating
in the 5K as a:

Donating On Behalf Of:

If you are donating on behalf of a team, what is the name of the individual or team you wish to contribute under?

T-Shirt Size:

Shirt Style:

How did you hear about the 5K Run for Freedom?

Other:

Family Information

Name:

Date of Birth:

T-Shirt Size:

Shirt Style:

Name:

Date of Birth:

T-Shirt Size:

Shirt Style:

Name:

Date of Birth:

T-Shirt Size:

Shirt Style:

Name:

Date of Birth:

T-Shirt Size:

Shirt Style:

Name:

Date of Birth:

T-shirt Size:

Shirt Style:

Name:

Date of Birth:

T-shirt Size:

Shirt Style:

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone:

E-mail: *

A receipt will be e-mailed to this address.

I am interested in providing a corporate sponsorship or gift donation through my company, church or organization.

Yes! I would like to receive information via e-mail.

Yes! I would like to be added to the general mailing list.

Comments or Questions:

add any additional information here

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *