5K Pledge

Email: info@milesforsmilestoledo.org
Phone: 419-474-8611

Registration Information

Choose the number of registrants 0 1 2 3 4 5 6 7 8 9 10

Note: Adult registration is $20, first child is $10, every other child is $5.

Billing Information

Cost:
* First Name:
Middle Initial:
* Last Name:
(Your name must appear as it does on your credit card)
* Dental Office Affiliation:
* Address:
* City:
* State:
* Zip:
* Phone:
* Email:
You must choose which race you will participate in below:
Please, enter your credit card information below for the $20 race fee (includes free t-shirt)
Mastercard
VISA
Discover
* Credit Card Number
* Expiration Month	01 02 03 04 05 06 07 08 09 10 11 12
* Expiration Year	2010 2011 2012 2013 2014 2015 2016 2017 2018