The 25th Arc Walk for Independence – March 20, 2021 (Virtual): Registration Form

WALKER REGISTRATION FEE: $25*

Please select the number of registrants you're entering. $25.oo per person.

REGISTRANT 1

Registrant 1 Name:*

Prefix First Middle Last

Registrant 1 Phone:*

Please enter your phone number where we can reach you if we have any question about your registration

Registrant 1 Email:*

Please enter your email address

Registrant 1 Address:

Street Address Street Name City State ZIP / Postal Code Country

Registrant 1 ANNIVERSARY T-SHIRT

$15 for S thru XL. $17 for XXL. Please select desired size

Registrant 1 BREAKFAST BURRITO

Would you like a breakfast burrito? Not available for registrants after March 18th.

Yes
No

REGISTRANT 2

Registrant 2 Name:*

Prefix First Middle Last

Registrant 2 Phone:*

Please enter your phone number where we can reach you if we have any question about your registration

Registrant 2 Email:*

Please enter your email address

Registrant 2 Address:

Street Address Street Name City State ZIP / Postal Code Country

Registrant 2 ANNIVERSARY T-SHIRT

$15 for S thru XL. $17 for XXL. Please select desired size

Registrant 2 BREAKFAST BURRITO

Would you like a breakfast burrito? Not available for registrants after March 18th.

Yes
No

REGISTRANT 3

Registrant 3 Name:*

Prefix First Middle Last

Registrant 3 Phone:*

Please enter your phone number where we can reach you if we have any question about your registration

Registrant 3 Email:*

Please enter your email address

Registrant 3 Address:

Street Address Street Name City State ZIP / Postal Code Country

Registrant 3 ANNIVERSARY T-SHIRT

$15 for S thru XL. $17 for XXL. Please select desired size

Registrant 3 BREAKFAST BURRITO

Would you like a breakfast burrito? Not available for registrants after March 18th.

Yes
No

REGISTRANT 4

Registrant 4 Name:*

Prefix First Middle Last

Registrant 4 Phone:*

Please enter your phone number where we can reach you if we have any question about your registration

Registrant 4 Email:*

Please enter your email address

Registrant 4 Address:

Street Address Street Name City State ZIP / Postal Code Country

Registrant 4 ANNIVERSARY T-SHIRT

$15 for S thru XL. $17 for XXL. Please select desired size

Registrant 4 BREAKFAST BURRITO

Would you like a breakfast burrito? Not available for registrants after March 18th.

Yes
No

REGISTRANT 5

Registrant 5 Name:*

Prefix First Middle Last

Registrant 5 Phone:*

Please enter your phone number where we can reach you if we have any question about your registration

Registrant 5 Email:*

Please enter your email address

Registrant 5 Address:

Street Address Street Name City State ZIP / Postal Code Country

Registrant 5 ANNIVERSARY T-SHIRT

$15 for S thru XL. $17 for XXL. Please select desired size

Registrant 5 BREAKFAST BURRITO

Would you like a breakfast burrito? Not available for registrants after March 18th.

Yes
No

REGISTRANT 6

Registrant 6 Name:*

Prefix First Middle Last

Registrant 6 Phone:*

Please enter your phone number where we can reach you if we have any question about your registration

Registrant 6 Email:*

Please enter your email address

Registrant 6 Address:

Street Address Street Name City State ZIP / Postal Code Country

Registrant 6 ANNIVERSARY T-SHIRT

$15 for S thru XL. $17 for XXL. Please select desired size

Registrant 6 BREAKFAST BURRITO

Would you like a breakfast burrito? Not available for registrants after March 18th.

Yes
No

REGISTRANT 7

Registrant 7 Name:*

Prefix First Middle Last

Registrant 7 Phone:*

Please enter your phone number where we can reach you if we have any question about your registration

Registrant 7 Email:*

Please enter your email address

Registrant 7 Address:

Street Address Street Name City State ZIP / Postal Code Country

Registrant 7 ANNIVERSARY T-SHIRT

$15 for S thru XL. $17 for XXL. Please select desired size

Registrant 7 BREAKFAST BURRITO

Would you like a breakfast burrito? Not available for registrants after March 18th.

Yes
No

REGISTRANT 8

Registrant 8 Name:*

Prefix First Middle Last

Registrant 8 Phone:*

Please enter your phone number where we can reach you if we have any question about your registration

Registrant 8 Email:*

Please enter your email address

Registrant 8 Address:

Street Address Street Name City State ZIP / Postal Code Country

Registrant 8 ANNIVERSARY T-SHIRT

$15 for S thru XL. $17 for XXL. Please select desired size

Registrant 8 BREAKFAST BURRITO

Would you like a breakfast burrito? Not available for registrants after March 18th.

Yes
No

REGISTRANT 9

Registrant 9 Name:*

Prefix First Middle Last

Registrant 9 Phone:*

Please enter your phone number where we can reach you if we have any question about your registration

Registrant 9 Email:*

Please enter your email address

Registrant 9 Address:

Street Address Street Name City State ZIP / Postal Code Country

Registrant 9 ANNIVERSARY T-SHIRT

$15 for S thru XL. $17 for XXL. Please select desired size

Registrant 9 BREAKFAST BURRITO

Would you like a breakfast burrito? Not available for registrants after March 18th.

Yes
No

REGISTRANT 10

Registrant 10 Name:*

Prefix First Middle Last

Registrant 10 Phone:*

Please enter your phone number where we can reach you if we have any question about your registration

Registrant 10 Email:*

Please enter your email address

Registrant 10 Address:

Street Address Street Name City State ZIP / Postal Code Country

Registrant 10 ANNIVERSARY T-SHIRT

$15 for S thru XL. $17 for XXL. Please select desired size

Registrant 10 BREAKFAST BURRITO

Would you like a breakfast burrito? Not available for registrants after March 18th.

Yes
No

ADDITIONAL DONATION AMOUNT (not walker registration fee)

Support individuals with intellectual and developmental disabilities. All additional donations are used to support The Arc Walk for Independence, but are not walker registration fees. The Arc Los Angeles & Orange Counties is a tax-exempt organization, under Section 501(c)(3) of the Internal Revenue Code; therefore, your donation is deductible to the full extent allowed by law. In addition to the Walker Registration Fee, I would like to make a tax-deductible donation of:

SPIRIT WALKER (not walker registration fee)

Spirit Walkers- My spirit is willing, but I will not be able to be on the "Zoom" Ceremony and prefer not to receive the gifts. Please include me among the “Spirit Walkers”.

Total

$0.00

WAIVER

Please read

CHECK BOTH BOXES BELOW IF YOU AGREE TO THE TERMS*

All listed Registrants hereby waive all claims against The Arc Los Angeles & Orange Counties, sponsors or any personnel for injury I might suffer in this event. I attest that I am physically fit and prepared for this special virtual walk event. I grant full permission for organizers to use photographs of me and quotations from me in legitimate accounts and promotions of this event.

I HAVE READ AND UNDERSTAND THE TERMS OF THIS WAIVER
CHECKING THIS BOX SERVES AS MY DIGITAL SIGNATURE

YOUR REGISTRATION IS ALMOST COMPLETE

Thank you for your registration to The Arc's 25th Walk for Independence (a virtual event)! We are excited to have you join us as we walk for hope and Walk The Walk via Zoom this year. We will e-mail your Zoom link and send you information on when and where to pick up your Burrito Breakfast and other goodies that day (March 20, 2021). Thank you for your patience and supporting The Arc during this pandemic.

CREDIT CARD INFORMATION

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

BILLING INFORMATION*

Same as Registrant 1

Street Address Street Name City State ZIP Code

Billing Name*

First Last

Billing Email*

COMMENTS

If you have any comments regarding registration, please use the box below.

TOTAL

$0.00