A Shot in the Dark Registration Form
August 21, 2015 - Willow Creek Golf Course
Please send this form in with your $75 per person to:
Prevent Blindness Iowa
1111 9th St. Suite 250
Des Moines, IA 50314
Email: [email protected] Or fax: 515-244-4718
Online registration: www.preventblindness.org/shotinthedark
Check enclosed (make payable to Prevent Blindness Iowa)
 Charge my credit card for $_________ ($75 per person)
MasterCard
Visa
Discover
Card # ________________________________
Expiration Date _________
Signature ________________________________________________
Please sign up as a foursome if possible. All other participants will be randomly assigned.
1.
_____________________________________________________________________
Captain Name
_____________________________________________________________________
Address
_____________________________________________________________________
City
State
Zip
_____________________________________________________________________
Phone
Email Address
2.
_____________________________________________________________________
Name
_____________________________________________________________________
Address
_____________________________________________________________________
City
State
Zip
_____________________________________________________________________
Email Address
3.
_____________________________________________________________________
Name
_____________________________________________________________________
Address
_____________________________________________________________________
City
State
Zip
_____________________________________________________________________
Email Address
4.
_____________________________________________________________________
Name
_____________________________________________________________________
Address
_____________________________________________________________________
City
State
Zip
_____________________________________________________________________
Email Address
Please call Prevent Blindness Iowa at 515-244-4341 or email
[email protected] with any questions.