Welcome to :: :: :: The 4th Annual Sickle Cell Walk

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Registration


2009 Sickle Cell Walk-A-Thon Registration Form

Name
Team Name, Company or Organization
Address *
Address 2
City
State / Province / Region
Postal / Zip Code
Phone
Alternate Number
Email

T-Shirt Size: Small Medium Large XL 2XL 3XL 4XL
Note: T-shirts are given for every $50.00 raised. Checks can be made to DKSCSSF and mailed to 1519 Union, PMB 224, Memphis, TN 38119. DO NOT MAIL CASH
Total Amount Raised	$
Sickle Cell Walk WAIVER: I hereby waive all claims against the Diggs Kraus Sickle Cell and Social Services Foundation, event sponsors and personnel for any injury I might suffer in this event. I attest that I am physically fit and prepared for this event. I understand that by agreeing to this waiver that I am assuming full responsibility for any and all risk of death or injury or property damage suffered by me while participating or volunteering in this event. I further grant full permission for the organization to use any photographs, video footage, and quotations from me in legitimate accounts and promotions of this and future events.

Signature:
Date:
(Parent or guardian’s signature required if under 18 years of age)

DKSCSSF * 6000 Poplar, Suite 250 * Memphis, TN 38119 *
(T) 901-271-5545 (F) 901-271-5546
Duplicate if needed

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