Childhood Stroke Awareness Walk
Silent Auction
Saturday, May 5, 2012
Fox Brook Park
2925 N. Barker Rd.
Brookfield WI 53045
Registration: 9:45 – 10:30
Walk/Auction Starts: 10:30
Auction Ends: 12:30
Walk Wrap Up: 1:00
Childhood Stroke Awareness Walk 2012
Registration Form
Fee: Adults $15.00 Children under 18 $5.00
Childhood Stroke Survivors Free
(Make checks to PSN)
Walker’s Name: _______________________
Address: _____________________________
_______________________________________
_______________________________________
Day Phone: ___________________________
Evening Phone: _______________________
Email: _______________________________
Number of Walkers: ___________________
Survivor Walking: Yes _____ No _____
Name of Survivor: ____________________
Waiver:
I agree to indemnify and hold harmless Pediatric Stroke Network (PSN), Waukesha County and all it’s employees and it’s representatives and Waukesha County Parks (WCP) from all cost, expense and liability arising out of my (or my child’s) participation in this event to benefit PSN. I do hereby waive all claims for damage or loss to me or my child’s person or property which may be caused by any act, or failure to act, by PSN or WCP, its officers, agents, or employees arising directly or indirectly from my or my child’s participation in this event, and I hereby assume liability for any loss, damage or other liability from such event. I give permission for PSN to use photographs of me or my child in promotion and advertising for PSN activities without compensation of any kind.
Signature: ________________________________
If under 18, parent or guardian must sign