• Please provide the following contact information:

  *Last Name
  *First Name
  Title
  Organization
  *Street Address
  Address (cont.)
  *City
  *State/Province
  *Zip/Postal Code
  Phone
  FAX
  *E-mail
  check here to use donation for race registration	10K Registration  Quantity None 1 2 3 4 5 ($20 each if postmarked by April 2; $25 thereafter)  2 MI Registration Quantity None 1 2 3 4 5 ($20/$25)  1 MI Registration Quantity None 1 2 3 4 5 ($17/$20)  Children's Race Registration Quantity None 1 2 3 4 5 ($8 all races)   Note: Application forms MUST be filled out and submitted separately

            * Required Fields

• Please provide donation information:

  	DONATION
  *Credit Card	VISA MasterCard American Express Discover
  *Cardholder Name
  *Card Number
  *Expiration Date

  As a token of our appreciation, while supplies last, we will send you a gift of a  coveted Martha's Run tee shirt for every donation of $20or more.

  If you are registering for the race, you may pick up your tee shirt with your packet on packet pick up, which is the evening before the race at the Mt. Lebanon Rec Center.

• Donation Amount	$

  Note: One Tee Shirt per equivalent donation, while supplies last.

  
  XXXL Tee Shirt                                 Quantity   

  XXL Tee Shirt                                    Quantity   

  XL Tee Shirt                                      Quantity   
  L Tee Shirt                                         Quantity   

  M Tee Shirt                                        Quantity   
  S Tee Shirt                                         Quantity   

  Kids 14-16 Tee Shirt                          Quantity   

  
  The Martha Fund thanks you sincerely for your donation.