| BUDDY WALK REGISTRATION FORM |
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| T-shirts may not be available for those who do not Pre-register by March 31st |
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| Registrations will also be accepted up to and on the day of the event. PHOTOCOPY THIS FORM AS NEEDED Last Name _____________________________________ First Name ___________________________________ Street Address _______________________________________________________________________________ City_____________________________________________________State ________Zip Code _______________ Phone______________________________ Email Address ___________________________________________ Team Name (if any):_________________________________________________ Pre-Registration donation levels # Adults _______ X $15.00 ea. ($20 day of walk) = ___________ # Children __________ X $5.00 each = _____________ (Ages 6-12) ($10 day of walk) Additional donation amount = ____________ Total = $ _____________ T- SHIRT SIZE(s) - Please write quantity needed Child Small # ___ Child Medium # ____ Adult Small #______ Adult Med. # ____ Adult Large # ____ Adult XL # ____ ____SORRY! I cannot participate in the walk, but please accept my donation to support the Hopes and Dreams Foundation, NDSS. $100 _________ $50 ________ $25 _________ Other _______ Checks are payable to Hopes and Dreams Foundation, Inc. Please complete and mail, with your payment, to: Hopes and Dreams Foundation, Inc. 517 Cedarbrook Road Southampton, PA 18966 Waiver: In consideration of me and/or my minor child being permitted to participate in the Buddy Walk, I hereby–for myself, my heirs and personal representatives–assume any and all risks which might be associated with the event. I further waive, release, discharge and covenant not to sue Hopes and Dreams Foundation, Inc., its officers, employees, sponsors, organizers, volunteers or other representatives or their successors and assigns, for any and all injuries or damages of any kind whatsoever suffered by myself and/or my minor child as a result of taking part in the events and any related activities. I also authorize the use by the Hopes and Dreams Foundation, and the National Down Syndrome Society of any photo, film or videotape taken of me or my minor child at the event for any purpose. Signature _______________________________________________ Date ___________ THIS REGISTRATION IS NOT VALID UNLESS SIGNED. |
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