2023 Jeremyah Memorial 5K Registration form | EMPACT Survivors of Suicide

Name*

First

Last

Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Phone

Email*

I will be walking in honor of

First

Last

Waiver: As a participant in the SOS Memorial Walk/Run:

-I discharge La Frontera/EMPACT-SPC, the event site, their management, their offices, board members, employees, sponsors, volunteers, and organizers from all claims of damages, actions and causes whatsoever in any matter arising from or growing out of my participation or that of my child during the event. I give full permission for the use of my name/photograph in this event.

-I agree that I will not attend the event if I am feeling ill and/or if I have been recently exposed to COVID-19 within 2 weeks prior to the event date.

I have read, understand, and agree to the terms of this agreement.

Printed Name of Participant (serves as electronic signature)

Date of Signature*