Mike’s Seafood Valentine’s Day 5K Run/Walk for Autism Online Registration

Registrant #1

Who are you registering? *

First Name *

Last Name *

Email Address *

Confirm Email *

Create Password *

This will be the password for your RunSignup account.

Confirm Password *

Date of Birth *

Format: mm/dd/yyyy

Used for age group calculations

Gender *

Male Female

Phone *

Valid formats include: 000-000-0000 or 0000000000

Street Address *

Country *

Zip Code *

City *

State *

5K Run

$40.00

— Group/Team Pricing May Apply (Group Pricing)

Walking-1 Mile

$40.00

— Group/Team Pricing May Apply (Group Pricing)

Yes No