Solidarity Walk

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Birth Date*

Date

Gender*

FemaleMaleOther

Could you please rate your running or walking skills and knowledge?*

1 is Worst, 5 is Best

I will...*

Join alone.Bring a person with me.

Companion Name*

First NameLast Name

Companion Email*

example@example.com

Companion Phone Number*

Please enter a valid phone number.

Your companion gender*

FemaleMaleOther

Date of birth*

Date

Contact Name (for the emergent situations)*

First NameLast Name

Contact Email*

example@example.com

Contact Phone Number*

Please enter a valid phone number.

Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Being of full age & in consideration of my participation in this event, I do hereby release & forever discharge Mary's Place Sexual Assault Center, its sponsors, and/or volunteers associated with this event from all claims arising out of any and all personal injuries, damages, expenses, and any loss of damage whatsoever resulting or which may result from my participation in the Solidarity Walk. I also certify that I am physically fit and sufficiently trained to compete in this event.

Signature of Participant or Legal Guardian (if under 18)

Signature