Memory Walk 2018

FUNDRAISER MEMORY WALK 2018

Queens Park Savannah- 29th September, 2018 at 7:00 a.m.

Please note one adult per form. Children require guardianship and can therefore be listed on the same form with an adult.

Which Registration Package(s) are you interested in? *

(Adult) - $100.00 (includes branded drawstring bag and cup, info and more) (Children under 16years) - $30.00 (includes branded cup and more)

* Indicates required field

Are you interested in purchasing Are you interested in purchasing an AZATT branded T'Shirt. If yes, what size? *

If no, please note that the official colour of the day is red *

I will wear red.

Gender *

Male Female

Contact Information

1. Name *

First

Last

The names of child/children if accompanying an adult *

3. Mailing Address *

4. Phone (H) *

Phone (C) *

5. Email *

Emergency Contact

Name *

First

Last

Phone Number *

Are there any medical conditions we need to be aware of before attending the Walk? *

Additional Information

How did you hear about this year's Walk? *

Other *

What is your closest connection to the cause? *

Would you like to share a personalized message that could be featured on our social media page? Please finish this sentence if you would like to : [Your name] is walking to honor ______. Examples: her granddad, John Smith or "all those facing Alzheimer's." *

ASSUMPTION OF RISK, RELEASE AND PERMISSION
The Memory Walk hosted by the Alzheimer's Association of Trinidad and Tobago involves walking around all or part of the Queen’s Park Savannah, Port-of-Spain. This walk is a potentially hazardous activity and is subject to risks such as, but not limited to, trips, slips, falls, effects of weather, traffic and conditions of the road, and interactions with other participants and members of the public along the route.
In consideration of being allowed to participate in this event:
(i) I declare that I am medically fit to walk.
(ii) I assume all risks, including bodily and personal injury, or death, property loss or other damages of any kind arising in any way out of my attendance or participation in the Memory Walk and related activities.
(iii) I accept responsibility to dress appropriately.
(iv) Although route maps, refreshments, and other assistance may be made available during this event, I am solely responsible for my own health and safety.
(v) I hereby for myself, my heirs, executors and administrators, release, discharge and agree not to sue Alzheimer's Association of Trinidad and Tobago, its directors, volunteers, employees, sponsors and agents, from any and all liability, claims, demands and causes of action whatsoever, arising out of my participation in or attendance at this event and related activities whether resulting from the negligence of any of the above or from any other cause.
(vi) I agree that my assumption of risk and release hereunder shall be as broad and inclusive as is permitted under applicable law. If any portion of this agreement is held invalid, the remainder shall continue in full force and effect.
(vii) I grant full permission in perpetuity to the organizers of this event to use, re-use, publish and re-publish my name and image as a participant in the event in photographs, video or other recordings.

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

If Participant is a minor, the parent or guardian must agree to the below:
I am the legal guardian of Participant, and I hereby consent to his/her participation. I have read the foregoing agreement, and I hereby agree on behalf of myself and Participant to its terms.

I agree to the terms and conditions *

Yes

Submit

Please PAY/ DEPOSIT at any RBC branch account Name: Alzheimer's Association of Trinidad and Tobago Account No. 100093110125138. Collect your bank slip scan and send to alztrinbago@gmail.com

FUNDRAISER MEMORY WALK 2018

Contact Information

​Emergency Contact

Additional Information

Please PAY/ DEPOSIT at any RBC branch ​account Name: Alzheimer's Association of Trinidad and Tobago Account No. 100093110125138. Collect your bank slip scan and send to alztrinbago@gmail.com

Emergency Contact

Please PAY/ DEPOSIT at any RBC branch account Name: Alzheimer's Association of Trinidad and Tobago Account No. 100093110125138. Collect your bank slip scan and send to alztrinbago@gmail.com