United Way of
Rockland County

Laps for Literacy Mall Walk Registration Form

Please fill in your information below. After you press the Submit button you will be asked to make your donation to United Way of Rockland via PayPal. If you prefer to pay by check please send your completed registration form to United Way of Rockland, along with your check made payable to United Way of Rockland.

* All fields marked with an asterisk are required

* First Name:         * Last Name:    

* Address:    

* City:         * State:         * Zip:    

Home Phone (e.g. 845-123-4567):    

Cell Phone (e.g. 845-123-4567):    

E-mail Address:    


Walkers Participating in Laps:

    First Walker' Name:

    Second Walker' Name:

    Third Walker' Name:

    Fourth Walker' Name:

    Fifth Walker' Name:

    Sixth Walker' Name:

    Family of Four at $25 = $
 
    Number of Children x $5 per child = $
 
    Number of Adults x $10 per adult = $
 
    Additional Family Members at $5 = $
 
    I can't participate, but here is my donation to
    help fund literacy programs in Rockland County
    through the United Way of Rockland
$
 
Total Payment $


TOP

Registration Form

If you prefer to pay by check please send your completed registration form to United Way of Rockland, along with your check made payable to United Way of Rockland:

PDF Form