![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 />,[object Object]](https://image.slidesharecdn.com/registration-110301095033-phpapp01/85/Registration-Forms-1-320.jpg)
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Registration Forms
- 2. Return to your Team Captain with your commitment/registration fee.
- 3. 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.
- 4. I give my full permission for the use of my name and photograph of this event.