Lyme Disease Awareness Walk Registration Form

September 15^th, 2007

Wells Beach, Maine

(Rain Date: September 22)

All proceeds to go to the Lyme Disease Association for there work with Lyme disease research and education.

Title: Dr Miss Mr. Mrs. Ms

First Name: ______________________________________________________________

Last Name:______________________________________________________________

Mailing Address: _________________________________________________________

________________________________________________________________________

________________________________________________________________________

Phone: ________________________________

E-mail:________________________________ (optional)

Employer/Organization: ____________________________________________________

City/Town: ______________________________________________________________

Business E-mail address: ______________________________

Business Phone Number: ______________________________

My T-shirt preference (sizes may vary by team and walk site)

Size: S M L XL

Gender:

M F

Age:

Registration fee: $10.00

Please include registration fee in form of cash, check or money order when returning your form. We will send you a confirmation/receipt via e-mail or mail.

Any questions please contact:

Jessica Platanitis (207) 251-0658 or jessplat10@hotmail.com

Helena Ackerson (207) 651-5074 or helena.ackerson@gmail.com

Thank you for your support!