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South Coast Diabetes Association

2010 Diabetes Fun Walk Pre - Registration

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* = required fields

 

All walkers must submit a registration form. If you are filling out a this form for more than one person, you may submit; then return to the form to add addional participants.

*Name: A name is required.

*Mailing Address: A valid address is required.

*City: A City is required.

*State: -------- Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming -------- is not a valid option.

*Zip: A value is required.5 digit zip codes only please..

Phone: Format: 541-123-4567

*Email: A valid email is required.A valid email is required..

*Confirm Email: A valid email is required.Email values do not match.

Please select all that apply:

Example: If you are a Team sponsor ($20 or more in donations and or sponsors), as well as bringing a pet; select both Team Sponsor and Pet Sponsor . The total to receive a T-shirt and bandana for pet would then be $30.

To be eligible for free lunch and souvenir t-shirt, we ask that you bring in a minimum of $20 or more in pledges and or donations.

***Select all that apply***

Individual Sponsor - Under $20 (t-shirt and lunch not included)
Self Sponsor - $20 or more (includes t-shirt and lunch
Team Sponsor -$20 or more per team member (includes t-shirt and lunch)
Pet Sponsor - $10 or more (includes bandana for your pet))
Volunteer - I would like to help at Diabetes Fun Walk. Please call or email me.

Team Name:

I cannot attend but please accept my donation of

T-shirt size:

---------- No shirt X Small Small Medium Large X Large XX Large XXX Large Please select No shirt if size is not needed.

Waiver and release of liablility Waiver is required and must be completed by every walker The day of the event each walker will be required to sign a waiver. This waiver will state the following: I hereby waive all claims against South Coast Diabetes Association, sponsors, or any personnel for injury I might suffer in this event. I attest that I am physically fit and prepared for this event. I grant full permission for organization to use photographs of me and quotations from me in legiti-mate accounts and promotions of this event. (parent or guardian’s signature required if less than 18 years of age).