879021383721247650-73479<br />NuPath Inc.<br />Walk the Walk!<br />Participant Registration and Waiver Form<br />(Required for each participant)<br />PLEASE PRINT ALL INFORMATION<br />Participant Name: ________________________________________________________ Age: ______________<br />Participant Address: _________________________________________________________________<br />City: ___________________________ State:______________________ Zip:_______________________<br />This is my address at Home Work (please check one)<br />Home Phone: (___) ______________ Work Phone (____) ________________ Fax (_____)_____________________<br />Employer: ______________________________ Email Address: _______________________________________<br />Team Name (If applicable): __________________________________________________________________<br />Team Captain Name: ________________________________ Team Affiliation: ________________________________<br /><ul><li>Waiver- Each team member MUST read and sign.
Return to your Team Captain with your commitment/registration fee.
As a participant in Walking the Walk: Making A Difference in Autism Support Services, I, for myself, my executor, administrators, and assigns to hereby release and discharge NuPath Inc., the event site, their management, their officers, members, sponsors, organizers, or their representatives, or their successors, and all cooperating businesses and organizations from all claims of damages, demands, actions, and causes whatsoever, in any manner arising or growing out of my participation or that of my child in this event.
I give my full permission for the use of my name and photograph of this event.
I also give my full permission for such first aid as is deemed necessary to be provided to me or my child on the premises or prior to transport to a hospital for further treatment. </li></ul>Participant Signature: _____________________________________________ Date: _____/_____/______<br /> (Signature of parent if under 18 or legal guardian if applicable)<br /><ul><li>II. Relationship to Autism: My Child/Children have autism: My family member has autism I have autism Other I work with and/or educate those touched by autism My friends family is touched by autism III. Registration Fee Enclosed Amount Enclosed $_________IV. My T-Shirt size is: (Please check appropriate size. If no size is indicated, Participant will receive an XL.)Youth Small Large (adult) Youth Medium X-Large (adult)Small (adult) 2X- Large (adult)Medium (adult) 3X-Large (adult)</li></ul>PH: 781.935.7057 * E-Mail: WalktheWalk@NuPathInc.org * 147 New Boston St. Woburn Ma 01801<br />NuPath Inc. is a non-profit 501(c)(3) organization<br />