Please Print: Legal Name

Name_____________________________________________________
(first) mi (last)

Sharing with_______________________ Need Room Mate _________

Address: _____________________________________________________


Day Phone (area code/number)_____________Evening Phone ___________  Cell Phone______________

E-mail:______________________________________________________

Date of Birth ________

t-shirt size_____

Select Packages
I plan to raise $3300 for BOMF_________(  Philadelphia Marathon Land Package)

I plan to raise $3900 for BOMF _____________              (Philadelphia Marathon Land and Air Package)

I am traveling as a Single ($200 additional)

I wish to stay additional nights ___________

NEED AIRFARE ________________
US Departure City and Date_______ US Return City and Date_______

Include Race Entry for Philadelphia Marathon ______

 
Please mail, fax or email registration form  to
Absolutely Amazing Travel
9841 Villa Pacific Drive
Huntington Beach, CA 92646
(714)963-5281 (800)707-0005
(714)963-3451 (fax)
info@amazingtravel.com

All Donations should be made out to BOMF

Someone from Back on My Feet will be in touch with further details about Fundraising.