REGISTRATION FORM
To participate in the CAMP LIGHTHEART WALK complete the following information and mail to Breast Cancer Options,101 Hurley Ave., Suite 10, Kingston NY 12401 or fax to 845/339-6784. Each participant must complete a registration form. Please print neatly.
EACH WALKER IS RESPONSIBLE FOR
SOLICITING THEIR OWN DONATIONS
Our goal is for each walker to raise a minimum of $100
NAME: ________________________________________________________________
ADDRESS: _____________________________________________________________
CITY/STATE/ZIP: _______________________________________________________
PHONE NUMBER: ______________________ EMAIL: __________________________
EMERGENCY CONTACT PERSON(S): ______________________________________
PHONE NUMBER: ______________________________________________________
ALLERGIES: ___________________________________________________________
___I AM A BREAST CANCER SURVIVOR
___I AM A RELATIVE/FRIEND OF A BREAST CANCER SURVIVOR
___I HAVE LOST A LOVED ONE TO BREAST CANCER
___ I JUST WANT TO SUPPORT BREAST CANCER SURVIVORS
___I AM UNABLE TO ATTEND BUT WOULD LIKE TO MAKE A DONATION: $_________
Anticipation Waiver and Agreement (unsigned waivers will not be processed)
I hereby attest that I am physically qualified to participate in this Walk. I understand that I should not enter and walk unless I am medically able and properly trained. I agree to abide by any decisions of the Walk official relative to my ability to safely complete the walk. I assume all risks associated with walking in this event including but not limited to: falls, contact with other participants, the effects of the weather, traffic and conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I for myself and anyone entitled to act on my behalf waive and release Breast Cancer Options and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event, even though that liability may arise out of negligence or carelessness on the part of the person named in this waiver. I understand that bicycles, skateboards, roller skates or blades and radio headsets are not allowed in the Walk, and I will abide by this guideline. I grant permission to Breast Cancer Options to use any photographs, motion pictures, records, or any other record of this event for any legitimate purpose.
Signature ____________________________________________________________
Date___________________________________
Parent or Guardian Signature if under 18 ___________________________________
Date ___________________________________
