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Support Walk/Volunteer Registration


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Personalization

* denotes required field

Walk only
I want to walk & volunteer
Name*
Address*
City / State / Zip*
Phone*
Email
How did you hear about the event?*
T-shirt (While supplies last. Size guaranteed by March 1, 2015)*
Sponsor name
Team leader's name
Team name
Event*
Registration Fee*
Name - In Honor of
Name - In Memory of
By submitting this registration form & payment, I understand & agree to the participation of the support walk. PRINT FULL NAME *
tax free

By printing your full name and submitting this registration form and payment, I understand that the Registration Fee is NON-REFUNDABLE.  I also understand and agree that, as a condition of participation in the Alzheimer’s Family Support Walk 2015, I will be required to sign this Indemnification and Waiver of Liability before participating in the event(s).  I certify that I have represented by my application for entry that my physical condition and training for this event is adequate to participate safely in this event and I acknowledge that I am familiar with the distances, rigors and risk of the event involved.  If I should suffer injury or illness, I authorize the official of the event to use their discretion to have me transported to a medical facility and I take full responsibility for this.  I hereby agree that in the event of cancellation due to storm, rain, winds, inclement weather or other ‘Act of God’ conditions, my registration will not be refunded.  In consideration of this entry, I intend to be legally bound, and do hereby for myself, heirs, executors and administrators, waive, release and discharge any and all claims against Alzheimer’s Family Organization, all Affiliates of The Villages, organizations sponsoring or conducting this event, or their volunteers, employees, representatives, or successors for any and all damages or injuries I may suffer.  I hereby grant permission for the use of my name and picture in any broadcast, brochure, or account of this event.  There will be NO SMOKING permitted on event premises.

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