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Celebrating 25 Years! Challenge 25 Registration

Please complete the information below to join the Challenge 25 campaign this year!

Contact Information

First Name
Last Name


Best phone number to reach you

Address Line 1
Address Line 2
ZIP/Postal Code
How do you prefer we contact you? We will use this method to reach out to you first.

If you like, upload a head-and-shoulder shot photo of yourself we can use to recognize our challengers.

Please tell us what inspires you to accept this challenge on behalf of CIS of Mid-America. How did you learn about us?
There's just one more question for you: