2012 Champlain Valley Buddy Walk® Registration Form
Sunday, October 14th, 2012; Gather at Noon. Walk begins at 1PM
Battery Park, Burlington

You may register yourself and your family/friends on-line using this form. If you are registering a family, please complete a separate registration form for each member. Please MAIL your payment (for registration and t-shirts if ordered) to: Lisa DeNatale, 319 South Union Street, Burlington, VT 05401. Checks should be made out to Champlain Valley Down Syndrome Group. Please register by September 17, 2012. You may also register on the day of the Buddy Walk, however we cannot guarantee availability of t-shirts.

You will be able to sign this form at the registration table at the day of the event.
Name *
Please enter first and last name.
Address *
City *
State *
Zip Code *
Phone
E-Mail address
Registration Fee (Includes T-shirt) *
If you do not wish to receive a t-shirt, the registration fee is $7 per individual.
Required
If Family Registration, how many members in family attending the Walk?
Enter # of family members
T-shirt Size *
Please check one size-all individuals even in families, need to register seperately.
Required
Make Checks Payable to: Champlain Valley Down Syndrome Group and mail to:
Champlain Valley Buddy Walk
c/o Lisa DeNatale
319 South Union Street
Burlington, VT 05401
Athlete Waiver and Release of Liability
I know that walking is a potentially hazardous activity, and that I should not walk unless I am medically able. I agree to abide by any decision of the organizers relative to my ability to safely participate in this event, including, but not limited to: falls, contact with other participants, traffic and the conditions of the road and course, all these risks being known and appreciated by me. I have read this waiver and knowing these facts, and in consideration of being permitted to participate in the Champlain Valley Buddy Walk®, I, for myself and for anyone entitled to act on my behalf waive and release the Champlain Valley Down Syndrome Group, its administrators, volunteers and other participants and owners and lessors of premises used to conduct this event, from all claims or liabilities of any kind arising out of my participation in the event. I consent to allow my picture or likeness to appear in any official documentary or coverage of the Champlain Valley Buddy Walk® event.

I/WE HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTANDING THAT I/WE GIVE UP SUBSTANTIAL RIGHTS BY SIGNING IT AND DO SO VOLUNTARILY.


Signature: ____________________________________________ Date: _________________________________
I/WE HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTANDING THAT I/WE GIVE UP SUBSTANTIAL RIGHTS BY CHECKING BELOW AND DO SO VOLUNTARILY. *
Please check if you agree to above Waiver and release. You will be asked for signature at day of event.
Required
The event will be held rain or shine. If you have any questions, please e-mail; lisadenatale@yahoo.com
Please print a copy of this form before hitting the SUBMIT button below: To Print, go to the top of the screen and click on File, and then Print. **DON'T FORGET to hit SUBMIT after print ***
This will give you a hard copy to sign and bring to registration. You may also mail printed registration in with check ahead of time as well.

Once you have printed, please hit SUBMIT button below and an electronic copy will be processed.

Thank you.
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