Registration Form Name____________________________________ Age / DOB___________________________ Address__________________________________ City walking
for_______________________ City / State / Zip____________________________
email_______________________________ Phone #__________________________________ Team walking
for_____________________ Do you have Diabetes? Yes / No T-SHIRT SIZE
_________
Walkable
West Branch - "Let's Get Moving 2005"
Did you participate last summer? Yes / No
If you were a prize winner, would you allow us
to list your name on the www.lgmnm.org website? Yes / No
Log
books have run out - please write down your name and miles and put in a drop
box.
Sponsored by: West Branch Centennial Committee
Exercise Program Liability Waiver
I understand that the benefits from participating in this project include learning more about the benefits of exercise goals.
I state that I am free from heart disease and other medical conditions, or that I have written permission from my doctor to participate in this program.
I release the sponsoring organization(s) and personnel from any responsibility or liability for any injury or health consequence that may result from my participation in this program.
My signature indicates that I have full knowledge of the purpose of the program, the benefits I may expect, and the risks involved. I agree to participate on this basis.
__________________________________ ___________________
Signature Date