be well 2016

Name *

Email *

Phone *

Ethnicity

African America/Black Native Hawaiian/Pacific Islander Asian Hispanic/Latino American Indian or Native American Caucasian/White

What neighborhood do you live in? *

Greater Park Hill East Montclair Northeast Park Hill Montbello Stapleton Northwest Aurora

Do you have transportation to and from the be well Block Captain Training Sessions? *Transportation is not provided by well or its affiliates.

Yes No

Where did you hear about the Block Captain Training Program?

Please list any dietary restrictions or allergies *be well provides a free meal prior to the start of each training session.

WAIVER OF LIABILITY AND RELEASE OF CLAIMS: In consideration of being permitted to participate in any program or activity offered by the Stapleton Foundation, I do hereby, for myself, my family, and our heirs and administrators, waive any and all liability rights and release any and all claims we may have against the Stapleton Foundation, employees, various sponsoring agencies, as well as paid and non-paid volunteers with respect to any damage, loss or injury resulting from or associated with such participation. Although I understand that a physician examination is not required for participation, it is highly advisable that I consult with a physician about my health before participating in athletic and strenuous activities. I have read this form and understand and consent to its content and knowingly request that I be allowed to participate in programs offered by the Stapleton Foundation. * *

Yes No

I consent to and allow any use and reproduction by be well, its partners, and/or affiliates of any and all photographs or videotapes taken of me and/or my child(ren) during our participation in the be well Tailgate party. I understand that be well will own the photographs and videotape and the right to use or reproduce such photographs and videotape in any media, as well as the right to edit them or prepare derivative works, for the purposes of promotion, advertising, fundraising and public relations. I hereby consent to be well to use my name or my child(ren)'s name, likeness or voice, and I agree that such use will not result in any liability to these parties for payment to any person or organization, including myself or my child(ren).

Yes No

be well Block Captain Registration