Instructions: Complete form and sign/date release of liability. Please use a separate form for each participant.  Return to organizers with payment made payable to the United Campus Ministry-PSU. If returning by mail, send to Fall Walking Program-2005, P. O. Box 713, Plymouth, NH 03264

Last Name                   First Name                 Age on 9/11/05 (needed for age category prizes. If not interested in prizes, just put 21)

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Check One:  _____Male    _____Female

Check One: ______PCC-UCC  _____PSU _____None of the preceeding

Mail Address __________________________________________________________________

City_____________________________________

Phone ___________________________________

E-mail address (if you desire to receive bulletins during program) ______________________________

Payment

Over 21        $10  _________

20 or younger  $5  _________

Release of Liability:  I know that walking and other forms of exercise may be potentially hazardous activities.  I assume all risks associated with participation in the Fall 2005 Walking Program that begins the 11th of September and ends the 12th of November. Knowing the facts and having read this release of liability, I or anyone entitled to act on my behalf releases the Health Ministries Team-PCC, the United Campus Ministry Program at PSU, Plymouth State University, all volunteers, all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this walking program even though that liability may be the result of negligence or carelessness on the part of persons named in this release.  I grant permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other recording of this program for any legitimate purpose related to this or similar events in the future.  I accept that the entry fee is non-refundable or transferable for any reason.

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Participant's Signature (parent or guardian if walker is under 18)                                               Date