April 25, 2015 Autism Awareness WALK McNeese State University -QUAD● Lake Charles, LA On-Site registration 7 - 7:45 am ● Walk Starts @ 8:00am 337-436-5001 – stnickcenter.org - [email protected] REGISTRATION FORM **Fill out separate forms for ALL PARTICIPANTS** Name __________________________________________________Phone:______________________________ Address ______________________________________ City ____________ St. ____ Zip__________ Email ____________________________________ TEAM NAME: AWARDS!!!! to be given to: *The Largest Team TEAM CAPTAINS TO PICK UP ALL SHIRTS FOR THE TEAM @ EVENT *The team with the most donations (above registration) *Team with best T Shirt design! Must enter shirt @ judges table on day of event BY 8AM PRE Registration (Must be received by APRIL 8th , 2015): AFTER 4/8 & DAY OF EVENT: ____ Walk - $30 _______ Walk- $25 _______Person with Autism- FREE T SHIRT Size: (please circle one) PRE REGISTERED participants guaranteed an event T Shirt Youth: YM YL Adult: S M L XL XXL XXXL XXXXL Optional: I would like to make a donation of $___________________ to Joining Hands for Autism. Total Payment: $___________________ Waiver I should not enter and run/walk unless I am medically able and properly trained. I agree to abide by any decision of a race/walk official relative to my ability to safely complete the run/walk. I assume all risks associated with running/walking in this event, including but not limited to falls, contact with other participants, and the effects of weather including extreme temperatures and/or humidity and road conditions. All such risks are known and appreciated by me. Having read the above, I and anyone entitled to act on my behalf, do waive and release Autism Services of SWLA, St. Nicholas Center for Early Intervention, and SWLA Autism Chapter, as well as their representatives, sponsors, and successors from all claims of liabilities of any kind arising out of my carelessness or on the part of the persons named in the waiver. **** REMEMBER TO SIGN THIS FORM!!!!!!! **** Signature: (Parent if under 18)________________________________________________Date: _____________________ To guarantee a T-Shirt, PRE registrations MUST BE RECEIVED by APRIL 8, 2015. Please make checks payable to : Autism Society SWLA P.O. Box 1805 Lake Charles, LA 70602 Credit card payments accepted!! contact: [email protected] Registrations will be accepted after April 8th as well as the day of the Walk. NO SHIRT FOR REGISTRATIONS RECEIVED AFTER APRIL 8TH