Walk a Mile Registration

First Name: *

Last Name: *

Name of Organization: *

Home or Work Address: *

City: *

State: *

Zip Code: *

Primary Phone Number: *

Alternate Phone Number:

Email Address: *

T-Shirt Size: *

Team Name:

NOTE: Sexual Trauma Services of the Midlands reserves the right to change any team name that is deemed inappropriate or offensive to participants (including names involving profanity or of a sexually implicit nature). Please use proper judgment when selecting names and artwork, our goal is a fun, pleasant atmosphere for everyone involved. Pre-Registration date ends March 25th - Limited t-shirts available for late registration.

In addition, registration must be completed by each individual team member. Registration for multiple walkers listed under same team organizers name will not be considered valid.

Event Registration: *

Walk a Mile in Her Shoes SAAM, Thursday, April 12, 2012 6:00 PM. The Walk will begin and end at the Columbia Convention Center , Columbia, SC. Pre-registration is now open for only $15 which includes a t-shirt and goody bag!If registering after March 25, 2012 the cost will be $20.

Survivor Sash: Each step we take is personal. This year we are offering survivors as well as their family and friends (secondary survivors) an option to wear a sash during Walk a Mile in Her Shoes ®. Please indicate below if you would like to take part:

Teal Sash:

I am a survivor and I would like to wear a teal sash during Walk a Mile in Her Shoes® to honor other survivors as well as myself, and to raise awareness about Sexual Assault.

White Sash:

I am a secondary survivor and I would like to wear a white sash during Walk a Mile in Her Shoes® to honor other survivors and to raise awareness about Sexual Assault.

NOTE: Please read documents listed at bottom of webpage below in regards to the Photographic Consent and the Waiver and Release form. These must be read and agreed upon before registration can be completed

Photographic Consent Release Form: *

Waiver and Release Form: *

Completed applications must be submitted online or returned via email, mail or fax to Sexual Trauma Services of the Midlands. If registering by email or fax, you will receive a confirmation of registration by email with a link to the agency’s Donate Now page, where you can pay. If paying by mail, please include your payment with the registration form. Your registration is not complete until payment has been received by STSM.

Fax #: 803-790-8282

Email: stsm@stsm.org

Mail: STSM, 3700 Forest Drive, Suite 350, Columbia, SC 29204

Attachment	Size
Photo Release	378.67 KB
Waiver and Release Form	465.29 KB

STSM Newsletter

Donate to STSM

We need your help! Donate to STSM using the button below. Donations to STSM are tax deductible.

STSM Community

Want to keep in touch with STSM? Follow us on Facebook and Twitter!