Name *

First Name

Last Name

Phone

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Name *

First Name

Last Name

Phone *

(###)

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do You Agree To The Waiver Of Liability Terms? *

If under the age of 18, a parent or legal guardian must read and agree to the terms of the waiver of liability. I specifically consent to participation in the Medina County Coalition for Suicide Prevention, Step Up to Prevent Suicide Community Walk on October 17, 2021. I am eighteen (18) years of age or older, or am consenting as a legal parent or guardian. I hereby release, indemnify and hold harmless Alternative Paths, Inc., members of the Medina County Coalition for Suicide Prevention, agents, employees, volunteers and assignees from any and all liability, claims actions, demands, and judgments arising out of any injury or loss sustained by myself, or my family in connection with travel to or from, and participation in the Step Up to Prevent Suicide Walk. I understand that participating in the Step Up to Prevent Suicide Walk is a physical activity and that participants should not enter or participate in any manner unless medically and physically able. I assume all risks associated with participation in the walk by myself or a participant for whom I am a legal parent or guardian, including injuries to person and property, or death, whether caused by negligence or otherwise. In the event of a medical emergency, I assume all costs associated with any treatment required by myself or a participant for whom I am a legal parent of guardian. I have read, fully understand, and voluntarily accept this waiver of liability.

Yes

No

Are You 18 Or Over? *

Yes

No