I am above 18 years of age or will be by the date of the event. * Yes No If no your parent must complete this form listing you as a Participating Minor   Title   First*Middle I.Last* Email * Phone* Address * Suite/Apt.# City * State* - - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WYZip* Gender * Female MaleDate of Birth* T-Shirt Size * Small Medium Large X Large XX Large XXX Large If any minors will be participating in the walk please list them, anyone over 16 must have their own registration form and fees completed   How did you find out about the walk? * I am walking in tribute to   Are You a Cervical Cancer Survivor?   Yes No Emergency Contact: First Name   Emergency Contact: Last Name   Emergency Contact Phone   I have read and understand the Terms and Conditions * Yes I have read and understand the Privacy Policy * Yes Electronic Signature * I understand that by typing my full name below I am attaching my electronic signature which is as valid as my written signature and that I understand all terms and conditions of registering for the Tia's Way 5k.

Tia's Way Terms & Conditions | Tia's Way Privacy Policy