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Learn More About the Walk

Support-A-Walk - Support Connection
Sunday, October 3, 2010, FDR State Park, 10 a.m.

Complete this online registration and donation form only if you are using a credit card.

To mail in your registration and donation, please click here to print mail-in registration form.

IMPORTANT NOTE: To receive a Walk tee-shirt, turn in $50 in donations BEFORE the day of the Walk, $25 for each additional shirt. PLEASE PICK UP TEE SHIRTS AT OUR OFFICE BEFORE THE DAY OF THE WALK. For details and everything you need to know about the Support-A-Walk, please click on "Learn More About the Walk." Questions? Please call 914-962-6402

You must complete and submit credit card information
in order for this to be processed

 
*Salutation:  
*First Name:  
*Last Name:  
*Address  
  Apt. or Suite No.  
*City  
*State  
*Zip Code  
  Country  
*Home Phone    
*E-Mail Address    
  Company Name  
  Business Phone  
 
   
  *Please check one
   I am walking:
   
Team Name (if applicable)  
Team Captain  
 Co-Captain  
   
 
Contribution Amount (US Dollars)  Please check one:
  $ 


If you would like to make this donation as a tribute in honor or memory of someone, please complete the following:
 
Please check one:                                                     
 
Name of the person to whom tribute is being paid:
 
   
Would you like us to send an acknowledgement of your tribute donation to someone? Please provide their name and address below:
Name:  
Address  
Apt. or Suite No.  
City  
State/Province  
Zip Code  
Country  

If you would like to include a personal message in your acknowledgement, please write below.
(Limit of 20 words.)
 
If you are walking, please check the box below to indicate that you have read and understand the following Waiver and Agreement. (Unchecked waivers will not be processed.)

I hereby attest that I am physically qualified to participate in this Walk. I understand that I should not enter and walk unless I am medically able and properly trained. I agree to abide by any decisions of the Walk official relative to my ability to safely complete the Walk. I assume all risks associated with walking in this event including but not limited to: falls, contact with other participants, the effects of the weather, traffic and conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I for myself and anyone entitled to act on my behalf waive and release the Taconic Road Runners Club, Support Connection, Inc., FDR State Park, and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event, even though that liability may arise out of negligence or carelessness on the part of the person named in this waiver. I understand that bicycles, skateboards, roller skates or blades and radio headsets are not allowed in the Walk, and I will abide by this guideline. I grant permissions to all of the foregoing to use any photographs, motion pictures, records, or any other record of this event for any legitimate purpose.
*   I accept and understand the terms of this waiver
 

            

THANK YOU for your donation!