Name ______________________________________________
Company/Team Name _________________________________
Street Address _______________________________________
City
___________________ State ________ Zip ____________
Phone ( ) ____________ Email ________________________
Total
# of walkers ______
___ YES! I will be there to support this
walk.
_____ Individual/Team Member Registration-
$10.00
_____ Family Registration(Up to 2 adults
& 2 children)$30.00
_____ Additional children
13 and under- $5.00 per child
Register before August 30th and get a Buddy Walk t-shirt.
Please indicate size(s) needed on bottom of form.
___ I want to be a Super Buddy Walker!
Donate $50 or more, above and beyond registration fee, and
become a Super Buddy
Walker.
Please accept my personal contribution of $____________
___ I cannot
participate in the walk, but please accept my
tax-deductible contribution:
$10______ $20
_______ $50_______ Other _________
Payment
Please make checks payable to DSAVP and mail to:
P.O. Box 1237, Yorktown, VA 23692
Volunteer:
__ Please contact Stephanie
(757) 870-8923 or Kim (757) 234-0895
to volunteer on the day of the event.
Waiver:
In consideration of me and/or my minor child being permitted to participate in the Buddy
Walk, I hereby-for myself, my heirs, and personal representatives- assume any and all risks
which might be associated with the event. I further waive, release, discharge and covenant
not to sue Buddy Walk of DSAVP , its officers, employees, sponsors, organizers, volunteers or
other representatives or their successors and assigns, for any and all injuries or damages of any
kind whatsoever suffered by myself and/ or my minor child as a result of taking part in the events
and any related activities. I also authorize the use by DSAVP of any photos, films or videotape
taken of me or my minor child at the event for any purpose.
Signature____________________________ Date______________
THIS REGISTRATION
FORM IS NOT VALID UNLESS SIGNED
T-shirt sizes (please enter quantity desired (1 per paid registrant)
6-12 months _______ 18 months ________ 24 months ________
Child small _______ Child medium ________ child
large ________
Adult small _______ Adult medium ________ Adult
large ________
Adult XL _______ Adult XXL ________