Participation Notification for the
"Rediscover Maryland"
Walk the 23 Counties and Baltimore City Program

Fill out this form and click on the send email button. The form will be emailed to the Rediscover Maryland committee for processing. Your program card will be mailed to the address you provide on the form.

First Name:   Last Name:
Address:      
       
City:   State:
Zip Code:   Telephone:
Email:

Supplemental information to help build a better program:

I am a (check one)   student   retiree   work-in-home   work-away-from-home
I walk mostly for   recreation   fitness   companionship   other
(select one or fill in "other")

My AVA Club affiliation is  

I am in the following age bracket (choose one):   6-18   19-24   25-30   31-40   41-50  
  51-60   61-70   71-80   81-90   91-100

I may be contacted for feedback about the "Rediscover Maryland" program.   yes   no

Thank you,
"Rediscover Maryland" Committee
Phill Wilder, John Carolus, & Jim Fons

     

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