Tri-State Trek

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Payment Type

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Contact Information

First Name *

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Last Name *

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Email *

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Phone Number *

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Address *

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City *

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State *

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Zip *

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Country *

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I Am (Relation to ALS) *

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Payment Information

Credit Card Number *

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Expiration Date *

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CVV * (The last 3 or 4 digits on the back of the card)

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Your Information

I Am (Relation to ALS) *

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I understand after I've completed this registration, I will be sent a link where I will upload the photo for this sign. Any photos uploaded after the deadline of May 23, 2025, will not have a printed sign at the event and will be included electronically only.

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Your Dedication

First name of person you are dedicating to *

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Last name of person you are dedicating to *

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Available mile number you wish to dedicate *

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