Walk-A-Thon Registration Form - Cristian Rivera Foundation

REGISTRATION FORM
Walk for Health Walk-A-Thon Ponte en Forma
Sunday April 17th, 2011

Participant's Name:
Group Name Participating:
Parent/Guardian's Name (if participant is under 18):
Address:
City:
State:
Zip:
Phone:
Email Address:
Gender:	Male Female
Date of Birth:
Age:
Wristband Size (If Applicable): XS, S, M, L, XL, XXL
T-Shirt Size (If Applicable): S, M, L, XL
Restaurant For Gift Card (If Applicable): Havana Cafe or Hudson River Cafe
Comments:
IMPORTANT ADVISORY, PLEASE READ CAREFULLY: In consideration of this entry, I on behalf of myself, my heirs, devises, executors, administrators, and/or assigns, hereby release, discharge, indemnify hold harmless the Cristian Rivera Foundation, the National Puerto Rican Day Parade, Inc., Diversity Foundation, City of New York, Bronx Borough President's Office, the organizations/corporations sponsoring or coordinating this event, or their employees, representatives, or successors for any and all claims, damages or injuries I may suffer. I hereby grant permission for the free use of my name, image and likeness in any advertisement, broadcast, brochure or account of this event in any medium now known or used in the future throughout the universe in infinity. I understand participants are not permitted to utilize the following during the walk-a-thon: Baby Joggers, Bicycles, Animals, Inline Skating, and Radio Headsets.
By checking this box, I am stating that I have read, understand, and agree with the above advisory.
PARTICIPANTS UNDER 18: By checking this box, I state that I have my parents or guardian's permission to participate, and that they have read the advisory.

Click here for PDF of Walk-A-Thon Application

For more information on upcoming Cristian Rivera Foundation events, please refer to this “Events” Page, as it is updated often.