Walk to Remember Registration

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Name
Email
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Telephone
  
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Name(s) of Participant(s)
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Age(s) of Participant(s)
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I would like my child's name recognized during the ceremony.
If yes, please provide child's name to be read.

Waiver

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I, for myself, and anyone entitled to act on my behalf, hereby release Hendricks Regional Health, all sponsors, cooperating organization, and other parties connected to the Walk to Remember from all liability arising out of my participation in the Walk to Remember. I waive all claims for damage or loss to me or my property, which may be caused by any act, or failure to act, by Hendricks Regional Health, its officers or agents arising directly or indirectly from my participation in this event; and I hereby assume liability for any loss, damage or other liability fro said event. Important: Walkers under the age of 18 must have this for signed by a parent or legal guardian. I consent to receive medical treatment, which may be deemed advisable in the event of injury or illness during the event. I attest that I am physically able to participate in this event. I grant full permission for organizers to use photographs, video and film of me, as well as quotations from me in legitimate accounts and promotions of this event by Hendricks Regional Health.

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© 2014 Hendricks Regional Health. All Rights Reserved.
Hendricks Regional Health is a hospital system with medical facilities and a physician group serving residents of Hendricks County in suburban Indianapolis, Indiana (IN), including the towns of Avon, Bainbridge, Brownsburg, Danville, Greencastle, Lizton, Monrovia and Plainfield.
1000 East Main Street Danville, Indiana 46122 Phone: (317) 745-4451
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