Geri Olympics Registration - West Virginia Health Care Association

1. List 10 residents who will be attending. This can change the day of the Olympics
2. Mail registration fee of $150
3. $20 for each shirt ordered

Please fill out the following information and then mail payment to:

IGOAL
Dr. Ted Muilenburg
PO Box 434
Institute, WV 25112

Contact Person*
First Last
Contact Email*
Facility Name*
Contact Address*
Street Address Address Line 2 City State ZIP Code
Contact Phone*
Team Members
Please list participating team members.
Team Member 1
Team Member 2
Team Member 3
Team Member 4
Team Member 5
Team Member 6
Team Member 7
Team Member 8
Team Member 9
Team Member 10
T-shirts
$20 a shirt includes: Geri logo and facility name.
Number of T-Shirts needed
Color of T-Shirt
T-Shirt sizes
Please list sizes needed here.
Payment
Please send payment to IGOAL Dr. Ted Muilenburg PO Box 434 Institute, WV 25112

Team Members