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 NameMiddle NameLast Name
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:

Area CodePhone Number
Email:
example@example.com
Agency Representing:
The participant is minor?*

YesNo
Participant’s Signature:*
Printed Name of Parent:*

First NameMiddle NameLast Name
Parent’s Signature:*
Should be Empty: