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Th
Annual


2014 Registration Contact Information

Name _________________________________________ Gender _________ Age_________
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 UPPER GREENHORN PARK at 8:30am on October 18th. 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 MUST be back to the Starting Location by 11:00.

For more information on the Yreka Breast Cancer Walk call Kris Taylor @ 842-1993. Drop off or send
registration to Shoppe Serendipity 404 S. Main Street, 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!

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.







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________