Lyme Disease Awareness Walk Registration Form

September 12th, 2009 

Wells Beach, Maine 

(Rain Date: September 19th)

Registration at 9 am, Walk at 10 am

All proceeds to benefit the Maine Lyme Disease Digital Library and the start up of another Maine Lyme Awareness project, LymeBuddies

Title:  Dr     Miss     Mr.     Mrs.     Ms 

Name: __________________________________________________________________

Mailing Address:

______________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Phone: _________________________________________________________________

E-mail:_________________________________________________________________

Age (optional): 

Registration fee: $10.00

Please include registration fee in form of cash, check or money order when returning

your form. We will send you a confirmation/receipt via e-mail or mail.

Send form and payment to Lyme Disease Awareness Walk C/O Jessica Platanitis 39 Smithwheel Rd #14 Old Orchard Beach, ME 04064

             Make all checks payable to Lyme Disease Awareness Walk.

Any questions please contact:

Jessica Platanitis (207) 251-0658 or lymeawareness@gmail.com