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KVF ‘Steps for Autism’ Walk
Saturday, April 25, 2015
Kiest Park, 3080 S. Hampton Rd., Dallas, TX 75224
2015 PARTICIPANT REGISTRATION FORM
Benefiting the Keyshawn Vaughn Foundation for Autism
Please mail completed registration forms to:
Keyshawn Vaughn Foundation,
Attn: Steps for Autism Walk
P.O. Box 166752, Irving, TX 75016
or email: [email protected]
First Name: ______________________________________Last Name:______________________
Street Address:___________________________________________________________________
City: _____________________________________ State: _______________ Zip: ______________
Primary Phone: ____________________ E-mail:________________________________________
Community Affiliation/School/Employer: _____________________________________________
Team Name (if applicable): _________________________________________________________
Fundraising Goal: ________________________________________________________________
T-Shirt Size: (please select one)
YS
YM
YL
XS
S
M
L
XL
XXL
3XL
Minimum Donation
Adult Participant: ______ x $15 = ______ until March 9. $25 fee for all adult registrations made between 3/10 - 4/25
Child Participant: ______ x $5 = ______ until March 9. $8 fee for all child registrations made between 3/10 - 4/25
*Attach an individual registration form for each participant. To learn more details about the
KVF ‘Steps for Autism’ Walk, https://fundly.com/KVFstepsforautism
TOTAL DUE: ______________________
Payment Information (please check):
o Cash
(Please mail to the address listed above)
o Check (Made payable to the Keyshawn Vaughn Foundation)
o Credit Card (Visa MC Discover Amex) Please visit our secure donation site to make your
payment https://fundly.com/KVFstepsforautism or you can use our PayPal acct.
WAIVER AGREEMENT: In consideration of my participation in the KVF ‘Steps for Autism’ Walk (the
“Event”) on April, 25, 2015, at Kiest Park, I hereby waive all claims against the Keyshawn Vaughn
Foundation, the City of Dallas, its affiliates, sponsors, cooperating organizations, or any personnel for
any injury that I may suffer while participating at this event. I grant permission to the Keyshawn
Vaughn Foundation to correspond with me via e-mail about the ‘Steps for Autism’ Walk and other
agency initiatives. I also grant permission to the Keyshawn Vaughn Foundation and its authorized
agents to use my name or any photographs, videotapes or recordings that are obtained during the
course of this event for future KVF advertising and promotion initiatives.
Participant’s Signature/Date__________________________________________________________
If under 18, Parent/Guardian’s Signature/Date____________________________________________