"Do It For Sam" 5K Walk

When:	Sunday July 31, 2016 @ 9:00 AM
	(Rain or Shine)

Where:	797 Indian Head St, Hanson, MA 02341

Registration Fee:	$25.00
Includes:	Donation to Samaritans Hope
	Event T-Shirt, Photo of Sammy
	Memorial Ribbon Pin, Bracelet
	A Healthy Snack and Water

	T-Shirt availability not guarenteed for registrations received after 6/26/16

All proceeds from this event's registration fee will be donated to Samaritan Hope in memory of "Samuel Philip Andrews" If you would like to donate without registering for this event, please click Samaritan Hope

Participant Name*

First NameLast Name

I certify that I am at least 18 Years Old?*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

Phone Number

Area CodePhone Number

T-Shirt Size*

Release Of Liability: (Adult)*

In consideration of the acceptance of this entry I waive all claims for myself and my heirs against the sponsors, cooperating and coordinating groups and any individuals associated with this event and will hold them harmless for any and all injuries which may result from my participation. I hereby give my permission to the media to use my name and photograph in the newspaper, broadcast, telecast of this event without limitation or obligation. I certify that I am physically fit for this event and understand the risks involved by participating in this event.

Parent / Guardian Consent:

I grant permission for my child to participation in “Do it For Sam” 5K walk. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend the Do it for Sam, its officers, directors and agents, or representatives associated with the event, arising from or in connection with my child attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the Do it for Sam, its officers, directors and agents, or representatives associated with the activity for reasonable attorney’s fees and expenses arising in connection therewith. I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.

Parent / Guardian:

First NameLast Name

Date:

Registration Fee / Donation*

USD"Do It For Sam" 5K Walk