National Recovery Month Walk Registration Form

Registration & Waiver of Liability Form
National Recovery Month Walk
Saturday, September 14, 2019
8:00 a.m. Registration | 9:00 a.m. Walk
Location: Bartlett Soccer Complex (5911 Thomas Ave.)

Light snacks and refreshments will be provided to participants.

Printed Name of Participant: *

First Name Middle Name Last Name

Address: *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Phone Number:

Area Code Phone Number

Email:

example@example.com

Agency Representing:

The participant is minor? *

Yes No

Participant’s Signature: *

Printed Name of Parent: *

First Name Middle Name Last Name

Parent’s Signature: *