Event Registration and Donation Form

Event Registration and Donation Form
Sept. 28, 2024 | Heritage Pond | Rupp Hollow Rd, Dubuque

REGISTRATION STARTS AT 9 AM | RACE BEGINS AT 10 AM
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Gender*

MaleFemale
Age*
T-Shirt Size*

SMLXL2XL3XL
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Phone Number*

Area CodePhone 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
My Products*
prevnext( X )
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: