Sunday June 15, 2015 Walk for Your Charity Jubilee Pavilion, Lakeview Park, Oshawa First Name: Address: City/Town: Telephone: Last Name: Fund: Postal Code: Email: Donations will be made to: Charity Name Charity Registration Number: Sponsor’s Name Address City, Province Postal Code Pledged Paid Email Jimmy Smith 123 Anywhere Street Whitby, ON L1N 9Z5 $20 $20 [email protected] Waiver/Release: By participating in the Durham Community Foundation Walk for Your Charity, I waive and release any and all claims for myself, heirs, executors and administrators against all sponsors, officials and organizers of the Durham Community Foundation Walk for Your Charity, including but not limited to Durham Community Foundation, their Board Members, sponsors and their properties, Investors, members and owners for injury, illness or death which may directly result from my participation in this event. I shall permit the free use of my name and picture in publicity resulting from the 2014 Durham Community Foundation Walk for Your Charity. I am physically fit to participate in this event. I have read, understood and agree with the contents of this waiver/release prior to participating in the 2014 Durham Community Foundation Walk for Your Charity. Name of Participant Signature of Participant Date Name of Guardian (If under 18) Signature of Guardian Date