2ND Annual WALK FOR SMA Edmonton & Area

Participant Registration Form

Full Name: Address: City: Province: Email: Age

(at date of walk)

_________________________________________________________ _________________________________________________________ _________________________________________________________ ________________ Postal Code: ________________

_________________________________________________________ : _________________________________________________________ YES NO

I will be collecting pledges to raise funds for Families SMA Canada Society.
If yes, please ensure that you complete your pledge form accurately and collect all sponsorship monies prior to the event. If you have any questions please contact Stacey Meighen at 780-929-5824 or Hali Harapchuk at 780-785-2792. All sponsorships of $10 or more are eligible for a charitable tax receipt. Important: All cheques must be made payable to Families of SMA Canada Society Submit completed registration forms via email to sma.edmonton@gmail.com or via fax to 780-986-4494. Please visit our website at www.walksmaedmonton.weebly.com for more information about the event. Early Bird Registration Fee: Regular Registration Fee: Registration Fees: $20.00 (up until July 31, 2012) $25.00

Children 12 and under are free, but a parent/legal guardian must complete a registration form for each child participating. Below is a link where sponsors can donate online: http://www.canadahelps.org/GivingPages/GivingPage.aspx?gpID=18940
I hereby release, waive, discharge and covenant not to sue and hold harmless the organizers of the event (and their affiliates) from any and all liability, claims, costs and expenses whatsoever arising out of or related to any loss, damage, or injury, that may be sustained in the Walk For SMA Edmonton and Area located within the City of Edmonton, Alberta on August 11, 2012. I further agree that the organizers may be taking photographs at the event and I agree that the organizers may use such photographs of me or that include me with or without my name and for any lawful purpose, including but not limited to publicity, illustration, advertising and web content.

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Date

Signature of Participant Or Parent/Legal Guardian of Childrent Under 18 Years Old