Event Registration and Donation Form

Event Registration and Donation Form
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Gender *

Male Female
Age *
Emergency Contact Information
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Please indicate the event you wish to enter:
Event *

5 K Run Race (prizes for the winners based on gender and age) 5 Mile Run Race (prizes for the winners based on gender and age) Downtown Dubuque Loop Ride (Ride winners determined by the amount of funds raised for the event) Mud Lake Loop Ride (Ride winners determined by the amount of funds raised for the event) Heritage Trail Loop Ride (Ride winners determined by the amount of funds raised for the event)
Event Fee and Donation
Event fee is required for registration. If you'd also like to make a donation, please choose a gift option below. All gifts are tax-deductible. *
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Event Fee $ 30.00
Required for registration

Gift $ 25.00
Cleaning products for a family

Gift $ 50.00
Food for a family

Gift $ 100.00
Help with utilities for a month

Gift $ 250.00
Help with rent for a month

Gift $ 500.00
Provides us muscle to continue our Mission

Total $ 0.00
Should be Empty:

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