EFVA 2007 Stroll Registration

Please provide the following contact information:

  Charlottesville

  Northern VA

  Richmond

  Roanoke

  Virginia Beach

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

Would you like to send emails to your friends, families, or co-workers asking for them to donate on behalf of your fundraising efforts?  Give us their names and emails and we will send them a request for you.

Name    Email  

Name    Email  

Name    Email  

Name    Email  

Name    Email  

Thank you for your support. 

We will email the contacts above on your behalf and any donations collected will be credited towards your fundraising efforts.

Please hit PRINT right now to have a copy of the registration for your records.  Bring this copy with you to the stroll as well as any other donations.  After it is printed, hit SUBMIT.

 The Epilepsy Foundation of Virginia is a non-profit 501(c)3.  Our tax ID number is 54-1379432.