8/2/2019 Walk a Mile for Autism - Walker Registration
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WALK A MILE FOR AUTISM REGISTRATION FORMHosted by The Autism
Society and The Special Olympics of Cumberland County
Sunday April 15, 2012 Registration: 8 am Event: 9 am to 1:30
pm
Daskyll Stadium, 3200 Ramsey Street in Fayetteville (Behind Reid
Ross Middle School)APPLICATION DEADLINE APRIL 9th, 2012
One form per person, one t-shirt per registration
Name:
__________________________________________________________
Address:
________________________________________________________
City: ________________________ State: _____________ Zip:
____________
Email:
___________________________________________________________
Phone: __________________________________ (including
areacode)
Gender: ____________________ Age Range (please circle) (12-24)
(25-44) (45+)
Check all that apply:
_____ Early Registration through April 9th (Ages 11 and up)
$10_____ Day of Walk Registration (Ages 11 and up) $15_____ Ages 10
and younger Free_____ Supporting with a donation Amount:
$_________
Payment information: Please make checks payable to Autism
Society of Cumberland County(If paying by check enter check number
and amount, if by cash please circle)Prepay: Check (#_________)
Amount: ___________ Cash paid on Day of Walk
Totals due: Please mail Registration to: ASCC
Event Registration Fees: $________ 351 Wagoner Dr, Suite 410
Other Tax Deductible Donation: $ ________ Fayetteville, NC
28303
Please submit Registration form and donations no later than
4/9/12.
For more information please call: Matthew Greene at: (910)
374-6384 or Kim Stepp (252) 945-6648
Statement of Participant/Parental Responsibilities &
ReleaseI hereby agree to abide by all rules, regulations and
policies as established by Fayetteville-Cumberland
Parks & Recreation (FCPR) and give approval for to
participate in any and all related activities during the
currentseason/session. I understand that injuries may occur from
participation, including transportation to and from activities,
that FCPRcannot guarantee injuries will not occur, and I give this
consent having informed myself of the inherent risks of
participation. For myselfand on behalf of participant, I do hereby
waive, release, absolve, indemnify and agree to hold harmless FCPR,
the City of Fayetteville,its employees, officers, agents, elected
officials, successors and assigns, parent or local league
organization, organizers, sponsors,supervisors, participants, and
persons transporting participant to and from activities against any
action, claim, cost, fee or expenses anyof them may incur arising
out of or defending any such action or claim related to such
participation. I also grant permission to managingpersonnel or
other department representatives, to authorize and obtain medical
care from any licensed physician, hospital or medicalclinic should
participant become ill or injured while participating in activities
when neither parent/guardian is available to grantauthorization for
emergency treatment. I have received, understand and agree to abide
by FCPRs Code of Conduct. I agree to return,upon request, any
equipment issued to participant in as good as condition when
received except for normal wear and tear. I agree thatphotographs,
recordings or any other record may be used for the purpose of
promoting programs operated by FCPR and the City ofFayetteville and
further agree to release any and all liability associated
therewith. I understand that a fee paid by me for participant isnot
refundable and hereby waive my rights for redemption of said fee. I
hereby take responsibility for the above information and
itsaccuracy to the best of my knowledge. I also understand that if
the information provided is not correct, participant will be
ineligible to
participate. I have read and fully understand that these terms
are not a mere recital and sign this agreement voluntarily.
Signature Date
Your donation is tax deductible within IRS regulations. Please
consult with your accountant.
351 Wagoner Drive, Suite 410 Fayetteville, NC 28303
Phone: (910) 826-3004/3005 Fax: (910) 868-5881
Email: [email protected] Website: www.autismcc.org
