Registration - 5k Walk for Life

Walker Registration Form

Subject: *
Name *
Address *
City *
State *
Zip *
E-mail Address: *
Home Phone *
Cell Phone
May we text you?	Yes No
Under 18? *	Yes No
T-shirt size (check one) *	Kids small Kids large Adult M Adult L Adult XL Adult XXL
Do you agree with the terms of the participation waiver? (see below) *	I agree I disagree


* Required

Waiver: I agree that by participating in this physical activity, 5K Walk for Life ("event") or use of any Event facility/premises, I do so at my own risk. I assume all risk of injury, illness, damage or loss to me or my property that might result, including without limitation, any loss or theft of personal property. I consent to medical treatment in the event of injury, accident, and/or illness during the Event. I agree on behalf of myself (and my personal representatives, heirs, executors, administrators, agents and assigns) to release and discharge The Women's Clinic of Columbus and any and all sponsors from any and all claims or causes of action, known or unknown, arising out of negligence. I acknowledge that I have carefully read this Waiver and Release and fully understand that is a release of liability. Checking the "I agree" box above constitutes permission to use participant's likeness without compensation, for advertising and publicity associated with the Event, unless prohibited by law. I will additionally permit the free use of my name and picture in broadcasting, telecast, et cetera. In perpetuity.