Registration

Please submit a registration form for each participant. Once you have completed registration, you may submit your fees online or see the bottom of this page for instructions for mailing a check or money order.

Your Name (required)

Gender

Team Name (if applicable)

Address (required)

Home Phone (required)

Cell Phone

Your Email (required)

T-shirt Size

Release

Check this box to indicate you have read & agree with the release above

Early Registration fees: until 3/26/17

Adults (18 and over): $20.00

Children (age 6- 17): $10.00

(Under 5 years – free)

Registration fees: after 3/26/17

Adults (18 and over): $25.00

Children (age 6- 17): $15.00

Registration fee includes T-Shirt

Registration Deadline is April 15, 2017

You may pay online or by mailing a check. Please make all checks and money orders payable to “Nassan’s 5K Walk for Autism” and mail to the following address:

Nassan’s Place, Inc.,
P O Box 833
East Orange, NJ 07019