Group Leader Registration Form

Please complete this form with information that will enable organizers to contact you anytime, if needed, with important information about the event or your group. You should also gather relevant contact information from your group members for the same purpose (example: event cancellation, important event notices). Complete information also helps us represent attendance to sponsors, transportation officials, and others who help put on the event.

Required fields are marked with a red asterisk(*)

* Full Name:
* Address:
Address (cont'd):
* City:
* State:	None Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
* Zip Code:
* Gender:	Male Female
Age:
* Phone Number:
* Email Address:
* Name you want listed as your Team Name: (this name should be easily recognizable to registering participants)
New Group Leader or Returning Group Leader:	New Returning
Organization your team represents (if different):
Organization's website (if applicable):
Is the Organization on Facebook?	Yes No
If on Facebook, under what Name?

Should you win a cash prize, please let us know where to send the check:
* Name on Check:
* Organization Name:
* Attention:
* Address:
Address (cont'd):
* City:
* State:	None Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
* Zip Code:

* Best time to attend a group leader meeting:

Weekday early morning Weekday lunch Weekday after work Weekend

* I have read the group leader information packet: