47394-37 PCC of Randolph Co. Walk Registration

Saturday, August 26, 2017

Pregnancy Care Center of Randolph County

Registration: 8:30 AM • Walk Begins: 9:00 AM

Register before 7/26 for a FREE t-shirt!

First Name *

Last Name *

I am: *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Church/School Group Affiliation

Email Address *

I am unable to walk, but will make a donation.

Have you walked in a W4L before? *

Shirt size needed *

Comments

WAIVER OF LIABILITY - In consideration for participating, the above mentioned, or any personal representative, shall not make any claim against, maintain an action against, or recover from Pregnancy Care Center of Randolph County for any injury, loss, damage, or death resulting from my participation in this event. Further, if the participant is under eighteen (18) years of age, on behalf of myself and any other parent or guardian of my child, I hereby release, indemnify and hold harmless Pregnancy Care Center of Randolph County from any and all liability for any loss or injury, including death, my child may suffer while participating as a result from participation in this activity. Additionally, I hereby authorize the use of my photo or likeness, regardless of media, by Pregnancy Care Center of Randolph County. *

I Agree

I Disagree