6th Annual

2013 Registration Contact Information

Name _________________________________________ Gender _________ Age_________ Email Mailing:___________________________________ Mailing Address:_______________ City________ State_________ Zip_________ Phone Number___________________________________ Breast Cancer Survivor Y/N Individual/Team (circle) Team Name_____________________________ Donation amount $30 ________________ Ck #_______________ Cash______________ Extra Fundraising Amount $_______________Ck# ________ Cash ______Total Raised $___________ Details: The event will take place at the Lower Greenhorn Park at 8:30am on October 19th. If you have pre-registered please arrive a half hour early. PLEASE plan to stay until ALL walkers have come in to encourage and support the effort ever walker has made to help make a difference. We are all walking for the same reason and for many this is a very emotional undertaking. All walkers will need to be back to the Starting Location by 11:00. Balloon Launch for the Cure will take place directly after the walk in Downtown Yreka. Balloons will be available throughout Main Street and will be launched at 12:00. For more information on the Yreka Breast Cancer Walk call Kris Taylor @ 842-1993. Drop off or send registration to Shoppe Serendipity 213 S. Broadway Suite B, Yreka Ca. 96097. This walk is a no frills event- and every attempt is made to keep the event costs to a minimum. All proceeds will go to the FMC (Fairchild Medical Center) Breast Cancer Ultra Sound Fund. I highly encourage extra fundraising. No person associated with the organization of the walk will profit from any funds brought in.

***Please makes checks payable to: Yreka Breast Cancer Walk

Be creative and dress up for the event! The Sweepvan (Fairchild Medical Auxiliary Van) will cruise the route to pick anyone up that is having difficulty completing the course, injured or has not completed the walk by 11am. If you are having difficulty and need assistance, please give the van a THUMBS DOWN sign. This will cue the van to pick you up and bring you either back to the starting point or to seek medical attention if needed. Runner/Walkers This is a run/walk event. However, for safety and courtesy, walkers please stay on the right of the roads/sidewalks and runners on the left. Walk /run single file when needed. Our annual Biker Escorts will again lead us safely through the route and add some extra fun to the event. Please give them your smiles and a high five-they are here for your safety.

Waiver I understand that while participating in the Yreka Breast Cancer Walk, I will be using public streets and facilities where many hazards exist and I am aware of and appreciate the risks that may result. I am also aware that accidents may occur during this event which could result in serious injury or death. I am voluntarily participating in this event with knowledge of all such risks. In the event of injury, accident or illness during the event, I consent to receive medical treatment which may be deemed advisable. In consideration for being permitted to permitted to participate in this event I agree to assume all risks and to release, hold harmless and covenant not to sue Kris Taylor, Sponsors, or any persons or groups associated with the Yreka Breast Cancer Walk for any claim, loss or liability that I may have arising out of my participation in the event, including bodily injury, death, or property damage, whether caused by negligence or carelessness of the releasees or otherwise. I intend by the waiver and release of Liability to release in advance, and to waive my rights and to discharge all of the releasees from all claims, losses or liabilities for death, bodily injury or property damage that I may have, or which may hereafter accrue to me, as a result of my participation in this event, even though that liability may arise from negligence or carelessness on the part of the releasees, from dangerous or defective property or equipment owned, maintained or controlled by them or because of their possible liability without fault. I understand and agree that this waiver and release of Liability is binding on my heirs, assigns and legal representatives. I am physically capable of completing this event. I understand I may be asked to provide doctors note or other proof that I am permitted to participate by my primary care health provider. If I am aware of or under treatment for any physical infirmity, ailment or illness, my medical care provider knows of and has approved my participation in this event. I acknowledge that I, and I alone, am solely responsible for my personal health and safety, and the property I bring with me. Photo Release I understand that my name and photograph may be used for promotional purposes related to the event. I hereby grant to the grantees the right to use my image in promotional materials or for any other legitimate purpose, create composite or computer manipulated materials from my image, use, reproduce, publish exhibit, distribute, and transmit my image in any media, included but not limited to print material, television, film, internet, DVD, and CDROM, assign the above rights to third parties. I waive the right to inspect or approve my image or materials that incorporate my image. I understand that I will receive no compensation in connection with the use of my image. I release the grantees from any liability, damages, or claims resulting from the use of my image, including claims for libel or invasion of privacy. I understand and agree that the terms of this paragraph are binding on my heirs, assigns and legal representatives. I have carefully read this waiver of Liability and Agreement and fully understand its contents. I am aware that by agreeing to this waiver and release of Liability, I am waiving legal rights and knowing this, I check I Agree of my own free will. I Agree Name_______________________________________________________Date________