Walk registration form 2018 .pdf


Nom original: Walk_registration form_2018.pdfAuteur: Genevieve Chartre

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SATURDAY MAY 19th 2018, Maisonneuve Park, Montréal
REGISTRATION FORM AND DONATION CONSIGNATION
Please write clearly in block letters all requested information.
WALKER INFORMATION (please provide the information below to register)
First Name:
☐Home Address

Registration fee suggested: $20/Adult or $30/Family (1 or 2 adults and children under 18 living at the same address)

Name:

Company (if applicable):

☐Work Address

Address:

City:

Telephone:

Email:

You are a: ☐Man ☐Woman

Preferred language of communication: ☐French ☐English

Your age: ☐18 to 25 years

☐26 to 35 years
☐Small

Your T-Shirt size - Adult:

☐Medium

☐36 to 45years
☐Large

Province:

Postal Code:

☐46 to 55 years ☐55 years and more

☐X-Large

Minor participant’s Name and First Name (in capital letters):
Size: ____________________

Child Age: ______________ T-Shirt

Minor participant’s Name and First Name (in capital letters):
Size: ____________________

Child Age: ______________ T-Shirt

Minor participant’s Name and First Name in capital letters):

Child Age: ______________ T-Shirt

Size: ____________________

I approve the participation in the walk of the Minor person (s) listed above, I agree and I adopt the below waiver.
Signature (parent or tutor):
Date:

TEAM INFORMATION

If you participate in the walk as a team, please provide the following information:

Team Name:
Captain’s Name:

Captain’s Contact (phone or Email):

REGISTRATION FEE: $20 per adult, $35 per family*, $5 per child aged 12 to 17. Checks are preferred and should be made to: THE CANADIAN HEMOPHILIA SOCIETY - QUEBEC CHAPTER (or
CHSQ). An official receipt will be issued on request for each donation of $20 or more.
* A family consists of up to two adults and two children living at the same address.
IMPORTANT INFORMATION ON BACK PAGE

PLEASE READ CAREFULLY BEFORE THE WALK:
WAIVER AND CONSENT TO USE OF PHOTOGRAPHS OF THE EVENT:
As a participant in the CHSQ Walk, I agree that: 1) I am fully responsible for my own safety during the course of the CHSQ Walk 2) I am aware of the risks inherent in my
participation in the Walk and I accept these risks, 3) I will cease to participate in the Walk if a representative of the CHSQ so requests.
IN CONSIDERATION of the permission granted to me to participate in the CHSQ Walk I, the undersigned, and my heirs, administrators, estate and claimants, hereby
release, disclaim and relinquish the Canadian Hemophilia Society - Quebec Chapter (CHSQ), its organization and sponsors, as well as its, agents, administrators, officials,
directors, employees, representatives, successors and estate OF ANY payments, claims, requests, actions, causes of action, damages, costs and expenses relating to my
death or any prejudice, loss or physical injury that I may suffer FOR ANY REASON WHATSOEVER related to my participation in the Walk, FOR ALL TIME and this EVEN IF
any of the above-mentioned persons contributed to this through his or her negligence. IN ADDITION, I AGREE TO ENSURE all above-mentioned persons against any
liability incurred by any one of them as a result of my participation in the Walk or in connection with this participation, and I AGREE TO INDEMNIFY THEM. BY
SUBMITTING THIS APPLICATION FORM, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND ACCEPTED THIS AGREEMENT, AS A RELEASE FORM, WAIVER,
DISCHARGE AND INDEMNITY AGAINST LIABILITY, and I DECLARE that I am physically fit to take part in the Walk.
I, the undersigned, also authorize the Canadian Hemophilia Society - Quebec Chapter (CHSQ), in whole or in part, to use photographs or footage produced for
promotional purposes in which my children and/or I appear, provided that such proofs or sequences, including voice-overs, are used exclusively, in whole or in part, by
the above-mentioned organization. In cases where a parent or guardian accompanies more than one child residing at the same address, the parent or guardian has the
right to sign a single waiver, as long as all children are enrolled on the list of participants that follows.

All personal information provided on this form is considered confidential.
The CHSQ uses this information to issue official receipts and keep in touch with its donors and participants in its events to inform them about its activities.
If you do not want CHSQ to contact you after the walk, check the Opt out option on this form:

Please, no contact ☐

How did you hear about the Walk?
☐Volunteer/CHSQ Employee

☐Friend/Family ☐Facebook

☐CHSQ Web Site

Do you know someone who has hemophilia or another bleeding disorder?

☐YES

☐Email

☐Adbvertising/Medias

☐Other:

☐NO

Once registered, you will receive the Psarticipant’s Handbook with all relevant details regarding the Walk. The day of the walk, bring this completed form and return
it to the registration table at Maisonneuve Park, with all your donations. If you cannot attend the Walk, please send your completed form and donations by regular
mail to the following address: The Red White & You Walk 2018, c/o SCHQ, 514-2120, Sherbrooke St. East, Montréal QC H2K 1C3.
For additional information, please contact Isabelle Velleman, program coordinator: 514 848-0666 or 1-877-870-0666, ext. 22 (email: programmes@schq.org )


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