WALKER'S NAME     _________________________________________________________
ADDRESS                    _________________________________________________________
CITY/STATE/ZIP        _________________________________________________________
PHONE, FAX, EMAIL        __________________________________________________                 

WAIVER:  In consideration of the acceptance of my entry, I hereby for my heirs, executors and administrators assume any and all risks which might be associated with the Walk.  I waive and release any and all rights and claims of any nature for damages which I might have against the organizers and all others connected with this event, their representatives, successors and assign for any and all injuries or damages of any kind whatsoever suffered by me or my property as a result of taking part in the walk and any related activities.

______________________________________                     ______________________________________
SIGNATURE                                                                                                        UNDER 18 PARENT/GUARDIAN SIGNATURE

SPONSOR'S                                                       ADDRESS INCLUDING                             
   NAME                                                             CITY, STATE AND ZIP                                       PLEDGED    COLLECTED