First Name:

        Address:   

               City:   

             State:

                Zip:

            Email:   

           Phone:

           Cell Phone:

Age On Race Day:

       Age Category:              Select One 12 and under 13 and over

The undersigned walker recognizes that Bridge of Hope Centre County (BOHCC) has not undertaken any duty or responsibility for his or her safety and agrees to assume full responsibility for all risk of bodily injury, death, disability and property damage as a result of participating in the BOHCC Mother's Day Walk. I understand the risks involved in participating in the BOHCC Mother's Day Walk and willingly and voluntarily accept these risks. By my signature, I hereby surrender any right to seek reimbursement from BOHCC and its affiliates, directors, officers, employees, volunteers, sponsors and other agents for injury sustained and liability incurred during my participation in the BOHCC Mother's Day Walk. I grant permission for photographs, video footage and/or interviews of me to be used for the purpose of, and as deemed appropriate by, Bridge of Hope Centre County.

Agree With Waiver: Select Yes

                Signature:       (Required for all Participants.  Parents Signature required if under 18)

Incomplete form will result in an error.

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