Walking toward a Heart-Healthy Lifestyle

Walk-A-Thon 2012 REGISTRATION FORM Saturday, April 14, 2012

Walking toward a Heart-Healthy Lifestyle “Keep thy heart with all diligence, For out of it are the issues of life”. Proverbs 4:23

Name_________________________________________________________________________ Address_______________________________________________________________________ City

State

Phone __________________________________

Zip Code

E-mail ______________________________

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I will be walking. Adult Registration Fee $20

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I will be walking. Children Registration Fee $10 (with-shirt) (age 13-17)

I will not be walking but would like to give a donation of _______

I will be walking. Children Registration Fee $5 (without t-shirt) (age 0-12) I will not be walking but would like to give a donation _______

T-Shirt Size – (please circle one) Adult: S M L

XL 2XL 3XL

4XL

Please send this completed form and your fee to: The Church of the Living God 1634 Alma Street Shreveport, LA 71108 Check-in begins at 9:00a.m. with the walk commencing at 9:30am Lee Hedges Stadium (Captain Shreve High School), 6115 East Kings Highway For further information, please call (318) 621-0400 or email: [email protected] or by FAX at (318) 636-6060 ALL PROCEEDS SUPPORT THE ELDER LOUIS GOREE & JOHNETTA CAPERS MAIDEN SCHOLARSHIP FUND AND THE AMERICAN HEART ASSOCIATION.