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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
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First Name
Last Name
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Best phone number to reach you
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
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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:
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