Walk of Hope Registration Form Pink Heart Funds is a non-profit 501c3 charity. All donations are tax-deductible. Name* First Middle Last Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Daytime Phone:Evening Phone:Date of Birth:* Gender:* M F TYPE OF ENTRYType of Entry* Individual Team What is your individual fundraising goal?*Team Name:*Captain's Name:*Phone Number:*What is your team fundraiser goal?*I am walking for:* In Honor Of: In Memory Of: Name of the person*ENTRY CATEGORYEntry Category (Check one)* 5K Run 3 Mile Family Fun Walk 1 Mile Family Fun Walk Doggy Dash - All pets must be leashed and attended by owner at all times Dog's Name:*REGISTRATION FEE $25.00 (Includes a T-Shirt)Balloon release and awards ceremony immediately following Walk. Please Note: Merchandise will NOT be mailed. Merchandise can be picked up beginning 10/9/15 Wednesday - Friday from 10 am to 3:00 pm or the day of the Walk at the registration tables. Adult T-Shirt (S) Price: $25.00 Quantity: Mark the quantity aboveAdult T-Shirt (M) Price: $25.00 Quantity: Mark the quantity aboveAdult T-Shirt (L) Price: $25.00 Quantity: Mark the quantity aboveAdult T-Shirt (XL) Price: $25.00 Quantity: Mark the quantity aboveAdult T-Shirt (2XL) Price: $25.00 Quantity: Mark the quantity aboveAdult T-Shirt (3XL) Price: $25.00 Quantity: Mark the quantity aboveChild T-Shirt (S) Price: $15.00 Quantity: Mark the quantity aboveChild T-Shirt (M) Price: $15.00 Quantity: Mark the quantity aboveChild T-Shirt (L) Price: $15.00 Quantity: Mark the quantity aboveChild T-Shirt (XL) Price: $15.00 Quantity: Mark the quantity abovePer Flower Ceremony/Honor ($3.00 each) Price: $3.00 Quantity: Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name PLEASE READ & SIGN BELOWPhotographic and results release and waiver and release claims* I agree All representations made and releases, waivers, covenants, consents and permissions given by me hereunder are given on behalf of me and any and all of my minor children or persons over whom I have guardianship participating in or attending the event. I give my consent and permission to Pink Heart Funds, Inc. d/b/a Pink Heart Funds, its affiliates and races, their sponsors and corporate sponsors, their successors, licensees, and assigns the irrevocable right to use, for any purpose whatsoever and without compensation, (i) any photographs, videotapes, audiotapes, or other recordings of me that are made during the course of this event (the "event"); and (ii) the results of my participation in this event (e.g., race time, name, participant number). I understand that (i) my consent to these provisions is given in consideration for being permitted to participate in this event; (ii) I may be removed from this competition if I do not follow all the rules of this event; and (iii) I am a voluntary participant in this event. I am in good physical condition and am solely responsible for my personal health, safety, and personal property. I know that this event is a potentially hazardous activity and I hereby voluntarily assume full and complete responsibility for, and the risk of, any injury or accident that may occur during my participation in this event (including, but not limited to, my fundraising activities associated with the event) or while on the event premises (collectively, "my participation"). To the fullest extent of the law, I, for myself, my next of kin, my heirs, administrators, and executors (collectively, "releasors"), hereby release and hold harmless and covenant not to file suit against (i) Pink Heart Funds, Inc., d/b/a Pink Heart Funds and all other Pink Heart Funds affiliates and their respective directors, officers, volunteers, agents and employees; (ii) any event sponsors; and (ill) all other persons or entities associated with this event (collectively, the "releasees") for any injury or damages I might suffer in connection with my participation. This release applies to any and all loss, liability, or claims I or my releasors may have arising out of my participation, including but not limited to, personal injury or damage suffered by me or others, whether such losses, liabilities, or claims be caused by falls, contact with and/or the actions of other participants, contact with fixed or non-fixed objects, contact with animals, conditions of the event premises, negligence of the releasees, risks not known to me or not reasonably foreseeable at this time, or otherwise. I understand that is am solely responsible and liable for all aspects of my fundraising activities associated with my participation, including, but not limited to, the safe and lawful conduct of any fundraising activities. This Photographic and Results Release and Waiver and Release of Claims (collectively, the "release") shall be construed under the laws of the state in which the event is held. In the event any provision of this release is deemed unenforceable by law, (is) Pink Heart Funds shall have the right to modify such provision to the extent necessary to be deemed enforceable; and (ii) all other provisions of this release shall remain in full force and effect. I understand that is have given up substantial rights by signing this release, and have signed it freely and voluntarily without any inducement, assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of liability to the greatest extent allowed by law.NameThis field is for validation purposes and should be left unchanged.