1st Annual 5K Walk-a-Thon Registration



Please fill out the form below to Register

* denotes mandatory field

Please choose below*
Start a Team
I want to start a Team, become a Team Captain and collect donations from friends and family.
Join a Team
I want to join an existing Team and collect donations from friends and family.
Join as an Individual
I want to join as an individual participant, not linked to a Team, and collect donations from friends and family.
Personal Information
Are you a Cancer survivor?:

Yes No

What Type:
Breast Cervical Prostate Colon  Lung

First Name:*

Last Name:*

Company Name:

Email:*

Address Line 1:

Address Line 2:

City:

State:

ZIP/Postal Code:

Phone:
T-Shirt Size:*
Fees*
Walker/Team Captain: $25.00
Individual Walker or Team Captain Registration-$25.00
Team: $200.00
Minimum of 10 Individuals-Total pymt of $200.00
Runners: $25.00
Runner Registration
Currency shown: US Dollars
 
Waiver/Agreement*
In consideration of this entry, I hereby for myself, my heirs, executors and administrators, waive any and all claims I may have for damages against the Southwyck and Silverlake Home Owners Association, Pearland Independent school District (PISD), the city of Pearland , and Africa Cancer Care Inc (ACCI), its sponsors, and all individuals associated with the event, their representatives and successors, and assigns for any and all injuries suffered by me in connection with the event, including pre- and post-Walk activities. I have been warned that I must be in good health to participate in this event, and I attest and verify that I am physically fit and have trained sufficiently for this event. I hereby grant permission to ACCI and its authorized agents to use my name and photographs, video tapes, motion pictures, recording and any other record of my participation in this event for any purpose. NO REFUNDS. Africa Cancer Care Inc. (ACCI) is interested in the health and well-being of each of the participants in the Walk 4 Love Ones-Walk 4 A cause Walk, February 25, 2012 held in Silverlake, Pearland, TX. ACCI may request information from the contracted ambulance service (hereafter referred to as emergency medical service, EMS) about the medical condition of you as a participant should an incident during the event which necessitates medical attention of you by "EMS". By signing this form you, as a participant in this event, hereby grant and authorize ACCI/ EMS to provide medical assistance and, upon the request of ACCI, release information to EMS and the event medical coordinator about your condition, including information which may be governed and protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), without other additional written authorization. You have the right to refuse medical care and advice from the event medical coordinator and "ACCI/EMS". In the event you need to be transported to a medical facility you authorize the ACCI to release the name of the medical facility to your family or responsible party. It is hereby agreed with your signature or with the signature of your responsible party you release and hold harmless Southwyck and Silverlake Home Owners Association, PISD, the city of Pearland , and ACCI for the disclosure of the requested information. I have read and understand the above information and I am authorizing the release of information to the event sponsors. I am voluntarily signing this form.
I agree to the warrant and covenant as stated above.