YWCA 2010 Discover Pink Walk Registration

Early Bird Registration Until September 15th (includes t-shirt)
Adults (ages 18 and older): $15.  $20 beginning September 16 (includes t-shirt if available).
Youth (ages 12 - 17): $10 - You can add youth to your registration under the children section.
Children (ages 11 and under): Free - Please add their names under the children section.
 
Online registration will close Thursday, October 7th at 9:00 PM.
You can also registrer the day of the event, beginning at 8:00 AM at the YWCA Salem building on Saturday, October 9th.
* Required field
Person to be registered
First Name: *
Last Name: *
Age: *
Phone: *
Email: *
Mailing Address:
City:
State:
Zip Code:
   
Would you like a T-shirt?   *T-shirt availability guaranteed only for those registered on or before Sept 15.
T-shirt size:
     
Breast Cancer Survivor? * Breast Cancer Survivors receive a free gift.
   

Team Information: *

 




Team Captain's Name:
or Team Name:
Children (if no children will be walking with you, leave this section blank)
Child's Name Age T-shirt Size  
 
 
 
 
Payment Information
Card Type: *
Name on credit card: *
Card Number: *
Expiration Date: *
Verification Code: *  
Optional Donation $: (Tax Deductable)

 

  * $50 will provide one breast exam.
* $125 will provide one breast exam and one mammogram.
Billing Address
Address: *
City: *
State: *
Zip Code: *
How did you hear about us?:
Waiver and Release
The undersigned voluntarily agrees to participate in the YWCA Discover Pink Walk for Breast Cancer Awareness. The undersigned recognizes that YWCA Salem has not undertaken any duty or responsibility for his or her safety and the undersigned agrees to assume full responsibility for all risk of bodily injury, death, disability and property damage as a result of participating in the Discover Pink Walk. The undersigned recognizes that these risks include but are not limited to: falls, road conditions and traffic on the walk route. By my signature, I hereby state that I understand the risks involved in participating in the Discover Pink Walk and willingly and voluntarily accept these risks. By my signature, I hereby surrender any right to seek reimbursement from YWCA Salem and its directors, officers, employees, volunteers and other agents for injury sustained and liability incurred during my participation in the activity described above. By my signature, I warrant that I am not relying on any oral representations, statements or inducement apart from the statements made on this form. I further give my permission to YWCA Salem to use any photographs taken at the event for reporting purposes and future promotion of the Discover Pink Walk. I understand that this waiver releases me and any minors accompanying me to this event.
I agree with the terms and conditions above. *
I would like to receive the YWCA e-News Letter.
 
Privacy Policy: The YWCA Salem holds personal privacy in the highest regard. The YWCA Salem will not sell, share or otherwise knowingly distribute your name, address, telephone number or other personal information to any third party without your permission and we will not use it for commercial purposes. We want you to be aware that you have choices about how the YWCA Salem uses your information. If you have questions or comments, please send an email to
ndunn@ywcasalem.org