Reliance House, Inc.

Walk-a-thon

 

September 27th 2008

 

Registration begins at 10am

Walk begins 10:30am

 

 

Walker Registration Form

 

Adults $10.00

Children $5.00

 

Name___________________________________Male:___Female:___Age_____

 

Company(optional)__________________________________________________

 

Address___________________________City:________State:_____Zip:_______

 

Signature_________________________parent signature____________________

                                                                                                (if under 18years old)

 

 

In consideration of this entry, I do hereby waive and claim for myself, my heirs and estate against the sponsors and organizations holding this event for any and all injuries suffered by me at said  event or while traveling to or returning there from.

 

 

Signed___________________________________________           Date___________________

 

 

 

Make check(s) payable and mail to:

Reliance House Inc

40 Broadway

Norwich ,CT 06360

RE: walk-a-thon

 

(860)887-6536