1997 Memory Walk Registration Form

(please type answers, print, and mail or fax this form)

Name:

Address:

City:

State: Zip:

Home Telephone Number:     Work Telephone Number:
()           ()

Male     Female     Age Category (Run Only):

Walk: 5-Mile or     1-Mile or    Patriot 5K Run (Fairfax Only)

I will walk in (check all sites that apply):   

Fairfax     Fredericksburg     Warrenton

Team Information

Team Captain:

Team Name:

Company/Club Name:

Enclosed is my/our check for: $

Credit Card Information:      Visa      Mastercard

Account Number:                                       Expiration Date:
          

Signature: (please do not type; print and then sign in pen ink)

Date:

I plan to raise additional dollars      Yes      No

I heard about Memory Walk from:

Friend  Mailing  Newspaper    

TV: Channel    Radio Station  

Other  

I cannot walk but would like to support programs by donating: $

Please make checks payable to: "The Alzheimer's Association, Northern Virginia Chapter" and indicate that you are paying Memory Walk fees.

Waiver and Release of Liability

I hereby waive all claims against the Alzheimer's Association, sponsors or any personnel for any injury I might suffer in this event. I attest that I am physically fit and prepared for this event. I grant full permission for organizers to use photographs of me and quotations from me in legitimate accounts and promotions of this event.

Signature: (please do not type; print and then sign in pen ink)

Parent or Guardian's signature if less than 18:

Date:

Send all information to:

Alzheimer's Association, Northern Virginia Chapter
10201 Lee Highway, Suite 210
Fairfax, VA 22030
(FAX) 703/359-4441

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Last updated: July 27, 1997

© 1997 & 1998 Alzheimer's Association, Northern Virginia Chapter. All rights reserved.