Do you accept the Challenge?

Please complete this form if you are interested in taking part in the Walk & Roll Challenge 2007.
Asterisks (*) indicate required fields. Your information will only be used by AACOG. Additionally, for privacy concerns, only your username and pledge information will be posted to our Pledge List page. All personal contact information will remain private.


Name*

Username*
Your username should be no more than 10 characters long and "G-rated".

Password*

Mailing Street Address*

City*

Zip Code*

Contact Number* () -

Alternate Phone () -

Email Address

Pledge Amount* miles

How will you alternatively commute?*
Check all that apply.
Cycling
Busing
Walking
Carpooling/Vanpooling
Eating Lunch At Office

Organization*
Enter N/A if you do not wish to provide your organization name.

Please click below to submit your information.  Once you have submitted this form, you should receive your confirmation letter via email (if provided) or US Mail (if no email is provided).
If you have any questions, please do not hesitate to e-mail bwilliams@aacog.com or call (210) 362-5246.

Last updated on May 08, 2008