First name:*

Last name:*

Street address:

City:*

State/Province (US/Canada)*

State/Province (if not in US/Canada)*

Zip/Postal code:

Nation:*

Primary phone number (please include your area code):

Best times to call, check all that apply:

Second phone number (optional):

Best times to call, check all that apply:

E-mail:*

Team name/Team number (if any):

My company has a matching gift program:*

Company name:

I would like to set a personal goal to raise (in U.S. dollars):

In addition to walking, I would like to help produce the event. I am available to volunteer (please check all that apply):

Gender:

Age range:

How did you hear about End Poverty Walkathon? (please check all that apply):*

Please attend an Info Session at Hearts & Minds (165 W 105 St, NY, NY). We will cover the same material at each. Choose one:

I can't make any of these times, but I am interested. Contact me to schedule a different time.

I can't attend in person. Please send me info how I can join a conference call for my info session.

Check the following box if it is NOT OK to include me on your e-mail list. (E-mail is used only for contact from Hearts & Minds, usually no more than once a month. We do not sell, rent or lend our list. It is always easy to be removed.):