Patriots Day Memorial Stair Climb Registration Form

Patriots Day Memorial Stair Climb Registration Form

Proceeds will benefit the public fire fund through The West Tennessee Healthcare Foundation
Location: The Ball Park at Jackson in Jackson TN Date: Spetember 10,2022 Time: 8:00 AM

T-shirt pickup on site after September 1,2022
Participant Details
Full Name

First Name Last Name
Age
Date of Birth

Month Day Year
Date
Email
example@example.com
Phone Number

Area Code Phone Number
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact Person

First Name Last Name
Emergency Person Phone Number

Area Code Phone Number
Relationship to Emergency Contact Person
T-shirt Size *

S M L XL 2XL 3XL 4XL
Please choose if you will be participating in full gear or no gear. *

Full Gear No Gear
Registration Payments

My Products *

Stair Climber $ 35.00

Donate $22.00 extra representing 2200 steps made that day $ 22.00

BE SURE TO HIT SUBMIT AT THE BOTTOM TO COMPLETE TRANSACTION.
Waiver & Release
I confirm that I am in good shape, health, and condition. I don't have any medical condition or medical history that will affect my participation in this event. I will follow the rules and regulations of the event. I acknowledge that this event requires physical activity and there are possible risks and danger. I release the event organizers for any responsibility in case of an accident, illness, or injury. I allow my photo to be taken during the event and used for event advertising and marketing. I confirm that all information in this registration form is accurate and true.
Participant's Signature

Clear
Date Signed

Month Day Year
Date
Parent/Guardian Signature (If participant is below 18 years old)

Clear
Contact for sponsorship opportunities or questions.

LaTrell Bellingsley 731.499.2145 or LBillingsley@jacksontn.gov
Should be Empty:

Participant Details