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 NameLast Name
Age
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number

Area CodePhone Number
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person

First NameLast Name
Emergency Person Phone Number

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

SMLXL2XL3XL4XL
Please choose if you will be participating in full gear or no gear.*

Full GearNo Gear
Registration Payments

My Products*

Stair Climber$35.00

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

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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

MonthDayYear
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