Welcome to the Black Health Coalition of Wisconsin (BHCW) Website ..... Thank you for participating in the 2008 Walk for Qualtiy Health! PICTURES COMING SOON! Check out the Photo Gallery from all the great events and programs!!! Visit the CONTACT US page to get in touch with us.
5th Annual African American Walk for Quality Health Individual/ Team Registration Form June 7, 2008 - ($10 Individual/$35 for a team (10 people max))
5th Annual African American Walk for Quality Health
Individual/ Team Registration Form
June 7, 2008 - ($10 Individual/$35 for a team (10 people max))
First Name: Last Name: Address: City: State: Zip: Work Telephone: Fax: Home Telephone: Email Address: Website : Company Name: Team Name (if applicable): Member Name Adult or Child Address Phone T-Shirt Size (Adult Sizes) CHOOSE ONE ADULT CHILD CHOOSE ONE Small Medium Large X-Large 2X-Large 3X-Large CHOOSE ONE ADULT CHILD CHOOSE ONE Small Medium Large X-Large 2X-Large 3X-Large CHOOSE ONE ADULT CHILD CHOOSE ONE Small Medium Large X-Large 2X-Large 3X-Large CHOOSE ONE ADULT CHILD CHOOSE ONE Small Medium Large X-Large 2X-Large 3X-Large CHOOSE ONE ADULT CHILD CHOOSE ONE Small Medium Large X-Large 2X-Large 3X-Large CHOOSE ONE ADULT CHILD CHOOSE ONE Small Medium Large X-Large 2X-Large 3X-Large CHOOSE ONE ADULT CHILD CHOOSE ONE Small Medium Large X-Large 2X-Large 3X-Large CHOOSE ONE ADULT CHILD CHOOSE ONE Small Medium Large X-Large 2X-Large 3X-Large CHOOSE ONE ADULT CHILD CHOOSE ONE Small Medium Large X-Large 2X-Large 3X-Large CHOOSE ONE ADULT CHILD CHOOSE ONE Small Medium Large X-Large 2X-Large 3X-Large
First Name: Last Name:
Address:
City: State: Zip:
Work Telephone: Fax: Home Telephone:
Email Address: Website :
Company Name:
Team Name (if applicable):
Participant Statement:
The African American Walk for Quality Health involved walking - an activity which may include risks such as , but not limited to, falls, interactions with other participants, effects of weather, traffic, and conditions of the road. In consideration of being allowed to participate in this event. I hereby expressly assume all risks, including personal injury and death, arising in any way out of my participate in the African American Walk of Quality Health and related activities. It is my responsibility to dress appropriately. I represent and warrant that I am physically fit and able to participate in this event and I agree to stop and request assistant if I experience any symptoms such as but not limited to , dizziness, excessive fatigue, shortness of breath, pain or any other conditions which would make it difficult or unsafe to continue. I agree, for myself, my heirs, executors and administrators, to not sue and to release, indemnify and hold harmless, the Black Health Coalition of Wisconsin, Inc. its affiliates, officers, directors, volunteers and employees, and all sponsoring business and organizations and their agents and employees, from any and all liability, claims, demands, and causes of action whatsoever, arising out of my participation in this event and related activities - where it results from the negligence of any of the above or from any other cause. This release and indemnification agreement shall be as broad and inclusive as is permitted by the state or province in which the event is conducted, if any portion of it is held invalid, the balance shall continue in full force and effect.
Please click Submit to continue.
The information you just inputted will be set directly to BHCW, and you will be directed to a print and obtain signatures from each participant and mailed in with your pledge sheet.
