Walk of Life Registration
Email:
Salutation:	(select one) Miss Ms Mrs. Mr. Dr.
First Name:
Last Name:
Street:
Unit/Apt.:
City:
Province:	(select one) Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Postal Code:
Phone:	ext.
Walk times begin every half hour. Participants will walk for a maximum of 30 minutes. Please plan to arrive approximately 15 minutes before your start time.
Desired Start Time:	(select one) 5:30 pm 6:30 pm
I HAVE READ AND CONSENT TO THE TERMS & CONDITIONS AS OUTLINED IN THE WAIVER:
WAIVER By registering as a participant in the Southlake Regional Health Centre/CHFC 2012 Walk of Life (here in referred to as the WOL) I understand that physical activity and endurance is required. I will comply with any and all instructions given by the event officials. I give Southlake Regional Health Centre and CHFC its sponsors, and their respective affiliates, advertisers, licensees and assigns (collectively CHFC), my irrevocable permission to use and reproduce my image and my name as photographed or otherwise recorded at the WOL, in any manner and in all media in perpetuity. For allowing me to participate in the WOL, I RELEASE and DISCHARGE Southlake Regional Health Centre/CHFC and will hold them harmless of any and all claims, injury or expense of any kind which may result from my participation in the WOL, whether resulting from the negligence of Southlake Regional Health Centre organizers or otherwise.