Journey home Inc.

10^th Anniversary Walkathon

Saturday, May 16, 2009 at 11:00 a.m.

Parking and Registration (10:30 am) at Hope Lutheran Church 1301 Vintage Lane, 14621

Registration and Contribution Tracking Form

Walk Participant Name______________________________________

Address____________________________________________________

City _____________________________State _____ Zip___________

Phone Number: h__________________ w___________________

E-mail Address ________________________________

Money will be Collected Day of the Event. Checks are Preferred.

Please Make Checks payable to Journey Home, Inc. Thank You!

Sponsor’s Name Cash

Address/City/State

Phone

Amount

Check

Total Amount Collected All Pages: ____________

Assumption of Risk, Release and Permission

In consideration of being allowed to participate in Journey Home, Inc.’s Walkathon, I hereby expressly assume all risks of personal injury, death or property loss arising in any way out of my participation. I represent that I am physically fit and able to participate in this event. I hereby release and agree not to sue Journey Home, Inc., its officers, directors, volunteers, employees, sponsors, and agents, from or in connection with any and all liability and claims arising out of my participation in this event. I grant full permission to the organizers of this event to use and publish my name and image as a participant in photographs, video or other recordings.

Signature___________________________________________________ Date_______________

If Participant is a minor or acts in accordance with a legal guardian, the parent or guardian must sign and agree to the below:

I am the parent and/or legal guardian of Participant, and I herby consent to his/her particpation. I have read the foregoing agreement, and I herby agree on behalf of myself and Participant to its terms.

Additional forms available at www.journeyhomegreece.org