4th Annual Shine The Light Domestic Violence Walk
Participant Information
Full Name
*
First Name
Last Name
Age
*
Zip Code
*
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Number of Family Members
Would you like to recognize a Victim or Survivor during the walk? If so, list their name.
Emergency Contact Details
Do you have any medical conditions, disabilities, or allergies?
If you would like to include an emergency contact, please fill out the necessary information below.
Emergency Contact Person
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Relationship
Waiver & Release
By checking this box, I grant Community Healing All Together Inc., its affiliates, and partners permission to use photos and/or video footage of me for promotional, educational, or informational purposes related to Shine the Light Domestic Violence Walk and other affiliated/non-affiliated programs, events, or marketing materials.
Photo/Video Release
By checking this box, I acknowledge and accept that Community Healing All Together Inc. and affiliated partners or vendors are not liable for any injuries, accidents, or loss of personal property that may occur during this event. I acknowledge that this walk requires physical activity and there are possible risks and dangers. I confirm that I am in good shape, health, and condition and that I don't have any medical condition or medical history that will affect my participation in this event. I confirm that all information in this registration form is accurate and true. I participate at my own risk.
Liability Release
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