Wufoo

Walker's first and last name *
Team Name (if walking with a team)
Raise $50 or more by the date of the walk and we'll give you a free shirt! (Checking this box does not guarantee you will get a shirt - you must bring at least $50 to the walk in order to receive one)
I pledge to raise $50 or more by the date of the walk, entitling me to a free 50th anniversary commemorative long-sleeved event t-shirt.
If you pledged to raise $50 or more, select your shirt size:
Date of Birth (under 18 must have guardian's permission) * MM / DD / YYYY
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Your Phone Number ### - ### - ####
Your Email Address
If 18 or older, provide a name and phone number of your emergency contact:

If you are under 18, please provide the name and phone number of your legal guardian: *
Please read and agree to the waiver (if you are under 18, please provide a name and phone number of your legal guardian):
In consideration of being permitted to participate in Step Up for The Arc Walk 2011, I hereby for myself, my heirs and personal representatives assume any and all risks which might be associated with the event. I further waive, release, discharge and indemnify The Arc of Atlantic County, the City of Ventnor, Holy Trinity Parish, volunteers, sponsors and others associated with this event from any and all claims of injuries or damages of any kind arising from participating in Step Up for The Arc.

I permit The Arc of Atlantic County the free use of my name and picture in any film/video/brochure/newspaper or in reports and promotions of this event or future events. *
I have read and agree to the above waiver
Do Not Fill This Out

Wufoo Powered