Walk-A-Thon Registration Form

Housing for the Homeless Walk-A-Thon Registration Form

Date: Saturday, May 22, 2010 ( Rain or Shine) Registration Time: 7:30 a.m. Start Time: 9:00 a.m.

Location: Mother’s Beach - Kennebunk, Maine Length: Two miles

Raise $100 and receive a logo t-shirt.

Bring a non-perishable food item and receive our gratitude.

Liability Waiver:

As a participant in the Housing for the Homeless Walk-A-Thon, I agree to assume all risks of personal injury, death, or property loss that occurs as a participant. I certify that I am physically capable of participating in this event. I grant full permission to the organizers of this event to use and publish my name and image as a participant in all media.

(Parent or guardian signs for walkers under 18 years of age)

_________________________________________________ Signature

_________________________________________________ Date

Registration/Pledge Form (please print clearly)

Name _________________________________________ Team Name ____________________________________

Address _______________________________________________________________________________________

Phone ________________________________ Email ________________________________________________

Contributions (Please make checks payable to York County Shelter Programs, Inc.

P.O. Box 820 - Alfred, Maine 04002)

PLEDGES: Please collect prior and bring to event!

Names Pledge Amount Amount Collected

(Suggested donation/registration fee of $25.00 for each walker, family, or team) $25

___________________________________________________________________________________

____________________________________________________________________________________

Total Collected: