Golden West Chapter

Are you interested in joining one or more of the Golden West Chapter Walks to Defeat ALS?

Please complete this preregistration form and we will notify you once you’re officially registered.

*1.

Question - Required - Which Golden West Chapter Walk to Defeat ALS event would you like to attend? (Select one or more)

	9/30 - Hawaii Walk to Defeat ALS
	9/30 - Central Valley Walk to Defeat ALS
	10/14 - Kern County Walk to Defeat ALS
	10/14 - Silicon Valley Walk to Defeat ALS
	10/21 - Monterey Bay Walk to Defeat ALS
	10/22 - Inland Empire Walk to Defeat ALS
	10/28 - East Bay Walk to Defeat ALS
	TBD - Los Angeles Walk to Defeat ALS

2.

Please enter your personal Information:

*

Name:

Title	First Required	Middle Required	Last Required

*

Email: Required

Street 1:

Street 2:

City/State/ZIP:

City	State	ZIP

Country:

*

Phone Number: Required

Employer:

Occupation:

*

Gender: Required

*

Date of Birth: Required

Date of Birth:

If you respond and have not already registered, you will receive periodic updates and communications from Golden West Chapter.

Yes, I would like to receive postal mail from Golden West Chapter

*3.

Question - Required - My preferred contact method is:

*4.

Question - Required - Is it OK for us to text you?

*5.

Question - Required - What is your ALS connection?

6.

Question - Not Required - If you have participated in the past, for how many years have you been a part of the event?

7.

Question - Not Required - Are you Walking in honor or in memory of someone?

8.

Question - Not Required - If you are participating in honor or in memory of someone, please list their name(s):

(Maximum response 255 chars, approx. 5 rows of text)

*9.

Question - Required - Participation Options: Select a Participation Type

10.

Question - Not Required - What is your fundraising goal? (you can adjust your goal at any time)

*11.

Question - Required - Participants who raise $100 or more earn a commemorative Walk to Defeat ALS t-shirt. What size are you?

12.

Question - Not Required - Did someone invite you to sign up? If so, please list their name:

(Maximum response 255 chars, approx. 5 rows of text)

Walk to Defeat ALS Preregistration

Are you interested in joining one or more of the Golden West Chapter Walks to Defeat ALS?