Miles for Smiles Registration Form




		Miles for Smiles Registration Form (Register Now, Donate Now)

First Name:

Last Name:

Email Address: (must be a valid e-mail address)

Company Name:

Address - Line1:

Address - Line2:

City:	State:	Zip:

Phone:
Team: Yes No
Team Name:
Weelchair access required: Yes No
T-Shirt size: S M L XL
	I cannot participate in the event, but I would still like to make a donation in support of the Center.

Number of Participants Under 10:

Credit Card Number:

Card Code:
(3 digit number on the back of cc)

Expiration:

Month:	Year:

Amount:	$

By hitting the "Submit Registration Form" button below, I hearby waive all claims against Broward Children's Center and event sponsors and personnel for any injury I might suffer in this event. I attest that I am physically fit and prepared for this event. I grant full permission for organizers to use photographs of me taken at the event for communication and educational purposes.

Group homes • Home care • Comp care • Kids Klinic •
Prescribed Pediatric Extended Care Program •
Pre-schools • Social Services • Respite care • Therapy •