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Register for 2012



Event date: Oct. 6 & 7, 2012. You can participate individually or as a team. A team participation has other fundraising guidelines. Please, click here for information and registration as a team.

Complete this form and send it to us by clicking on the "Submit" button. Then you can pay your $65 (50 euros) registration fee by mailing a check to Stichting A Sister's Hope, 6263 N. McCormick Blvd. #104, Chicago IL 60659. In The Netherlands, mail to: Postbus 76713, 1070KA Amsterdam, The Netherlands. You also can pay by bank transfer (PIN) from a European bank account to Stichting A Sister's Hope, Postbank-Amsterdam, Acct. #2947137. Currently, you can pay securely by credit card via PayPal to info@asistershope.org.

To download this form, click here.

Name:
Adress:
City, State:
Postal/Zip code:    
Phone: Phone 2:
Email:
Gender: Woman Man  
Birth date: dd-mm-yy
Participation as: Walker
  Teamleader    Name:
  Teammember         Name:
  Crew (full weekend available)
I had/have breast cancer: Yes No
Size of the T-shirt: Small Medium Large X-Large
I will pay my registeration fee of € 50,00: Check/Credit Card
Transfer to the A Sister's Hope bank account
I have knowledge of the A Sister's Hope 60km Walk by:
Stichting A Sister's Hope can share my contact information with other Walk participants in my area: Yes No

I understand that by registering for A Sister's Hope 60K I am agreeing to raise the minimum pledge amount of €1,500 ($2,000 U.S.) in order to participate in the two-day walk in October. If I do not reach the minimum donation amount of $2,000, I understand that I will not be allowed to walk. I also understand that if I do not Walk that weekend, I am under no obligation to meet the $2,000/€1,500 minimum, and additionally understand that my registration fee of $65/€50 and any pledges that have been received by A Sister's Hope in support of my walk are non-refundable and will remain as donations to the event.

I further agree to hold harmless A Sister's Hope and associated independent contractors should I suffer injury during my training or on the event.

I agree