Fall 2006 Walking Program— Heeding Henry David

Last Name ________________________ First Name ____________________________

Street Address _______________________________

City ________________________ ZIP Code ____________________

Telephone Number ___________________________

E-mail Address ______________________________

Legalese for Waiver and Release:

I know that walking is potentially a hazardous activity. I should not enter and walk in this program unless I am medically able and properly trained. I agree to abide by any decision of program officials relative to my ability to safely complete the program. I assume all risk associated with participating including, but not limited to falls, contact with other participants, the effects of the road and traffic on my exercise program, all such risks being known and appreciated by me. Having read this waiver and knowing these facts, I for myself and anyone entitled to act on my behalf, waive and release the United Campus Ministry at Plymouth State University, the Health Ministry Team of Plymouth Congregational Church—UCC and Plymouth State University, coordinating groups, individuals associated with the walking program, all sponsors and their representatives, employees, and successors from all claims or liabilities of any kind suffered in connection with this program. I also hereby grant full permission to any and all of the foregoing to use my likeness in all media including pictures, photographs, or any other record of this event for any legitimate purpose.

________________________________________ ________________________

(Participant Signature) (Date)

If you are under eighteen, please have your parent or guardian sign below:

This certifies that I allow my child to participate in the 2006 Walking Program

______________________________ ____________________________

(Parent or Guardian Signature) (Date)

Costs:

Adult: $10

Non-adult (Age 20 or younger): $5

(If paying by check, please make check out to UCM at PSU with memo noting “Fall 2006 Walking Program”. All fees for running this program will be donated to Church World Service, thus the fee is totally deductible as a contribution by you)

Return registration form to: Larry Spencer, P. O. Box 713, Plymouth, NH 03264 or Larry Spencer, Dept. of Biological Sciences, MSC #64, PSU