5k Registration Form 5K Registration Form Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Registration for youth (12 and under) or adult?*Youth ($10)Adult ($20)Youth Shirt SizeXSSMLAdult Shirt SizeSMLXL2XL$10 Youth Registration Fee - Payment Method*Credit CardCheck$20 Adult Registration Fee - Payment Method*Credit CardCheckYou have selected to pay by check. Please fill out your $10 check to Rock Prairie Church with the memo "5k". Mail before September 13th to 421 N Ash St, Tipton, IN, 46072.You have selected to pay by check. Please fill out your $20 check to Rock Prairie Church with the memo "5k". Mail before September 13th to 421 N Ash St, Tipton, IN, 46072.Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Agree to Payment* I agree that the following total can be charged to my credit card.Total $0.00 CAPTCHA
