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2016 LifeChain Participation Report

Please submit this registration form on or before September 23rd
(Please note that late registrations are always accepted)
After receiving this form we will make your route assignment
You will be called Sept. 29th - Oct 1st and told where and when to pick up your signs and assignment


Please fill out this form completely to insure the accuracy of our records.

Church or Group Name:
Denomination:
Address:
City:   Zip:   Phone:
Pastor Name:

Locations

North Hwy 100 (Mayfair Mall Area)
Bluemound Rd. & Hwy 100 Area
South Hwy 100 (shopping district)
  South Hwy 100 in Hales Corners
West Bluemound Rd., West from Brookfield Sq.
West Bluemound Rd., East from Barker Rd.

Please select location preferences below

First Location Preference:   Second Location Preference:
 

We request a one-dollar per adult donation in advance to cover the cost of organizing the LifeChain. Please submit one check for your entire group payable to LifeChain.

Anticipated Number of people participating:   Donation Amount:


Please Note: The Contact Person listed below will be called for sign and route assignment pickup and will receive future mailings.

Contact Person:
Address:   Phone:
City:   Zip:   Work Phone:
Assistant Contact Person:
Address:   Phone:
City:   Zip:   Work Phone:

Please mail checks to: Milwaukee LifeChain P.O. Box 679  Hales Corners, WI 53130-0679