Can We Count On You Census Community Walkathon
Complete one form PER participant.
Registered walkers will receive a free t-shirt
(while supplies last)
Date of Birth
Address Line 2
State / Province / Region
Postal / Zip Code
How will you be walking?
I am walking as an individual.
I am walking as a team. (Name your team below)
Team Name (If Applicable)
Choose Your Starting Location
Vernard L. Alsberry Jr Municipal Center (3601 W. 183rd) to Hazel Crest Public Safety Bldg. 3000 W 170th Pl. (2.2 Miles) START TIME- 10:00
Head north on Fountainbleau Dr, Continue onto Chantilly Ln, Continue onto Fountainbleau Dr, LEFT onto Kedzie Ave, RIGHT onto Ridgewood Dr, RIGHT onto Oakwood Dr, Continue onto California Ave (DESTINATION WILL BE ON THE RIGHT)
Teddy’s Meat & Fruit Market (17531 Kedzie Ave.) to Hazel Crest Public Safety Building (3000 W. 170th Pl) (1.0 mile) Start Time: 10:30am
North toward Longfellow Ave, RIGHT onto Lexington Dr, Turn LEFT onto Holmes Ave, RIGHT onto Longfellow Ave, RIGHT onto 172nd St, LEFT onto California Ave (DESTINATION WILL BE ON THE RIGHT)
Can We Count On You Census Community Walkathon General Release and Waiver
For good and valuable consideration, including me and my minor child(ren)’s voluntary participation in the Count On Me Census Walk-A-Thon (the “Event”), I, personally, and on behalf of, and as parent or legal guardian of, the minor child(ren) identified below, and on behalf of anyone acting on my behalf or on behalf of my minor child(ren), including, but not limited to attorneys, representatives, agents, heirs, executors, administrators, assigns, insurers, or any other person or entity asserting claims through me and/or my child(ren), agree to release, indemnify, defend, hold harmless and forever discharge the following persons and entities:
The Count On Me Census Walk-A-Thon, The Village of Hazel Crest and all of its respective directors, officers, shareholders, members, managers, partners, board members, agents, representatives, employees, subsidiaries, successors, parents, heirs, executors, administrators, representatives and affiliates (collectively, the “Releasees”), from and against any and all claims, suits, losses, damages, judgments, expenses, costs, and liabilities (including, without limitation, reasonable attorney, expert witness and court reporter fees and court costs and expenses), which hereinafter may accrue or arise against the Releasees and which in any way arise out of or are in any way related to (a) my or my minor child(ren)’s participation in and/or presence at the Event, and (b) the use of my and/or minor child(ren)’s name, image, likeness and/or quotations in media platform, including, but not limited to, print, television, radio, mobile and the internet, in any advertisement or promotion or fundraising effort relating to or supporting ECC Walk-A-Thon and/or the Village of Hazel Crest.
I HAVE FULLY READ THIS RELEASE AND WAIVER, AND HAVE BEEN FULLY INFORMED REGARDING THE EVENT AND ANY QUESTIONS I HAD REGARDING THE EVENT OR THIS DOCUMENT HAVE BEEN ANSWERED.
I UNDERSTAND THE DANGER OF PERSONAL INJURY OR DEATH THAT MAY RESULT FROM PARTICIPATING IN AND/OR BEING PRESENT AT THE EVENT.
I UNDERSTAND THE POSSIBILITY AND RISKS TO MY PERSONAL PROPERTY THAT MIGHT RESULT FROM MY PARTICIPATING IN AND/OR BEING PRESENT AT THE EVENT.
I ASSUME ANY AND ALL RISK THAT IS IN ANY WAY ASSOCIATED WITH, RELATED TO OR OCCURS AS A RESULT OF MY OR MY MINOR CHILD(REN)’S PARTICIPATION IN AND/OR BEING PRESENT AT THE EVENT.
I HEREBY GIVE RELEASEES OR ANY ONE OF THEM IRREVOCABLE PERMISSION TO USE MY AND/OR MY CHILD(REN)’S NAME, IMAGE, LIKENESS AND/OR QUOTATION ON THE INTERNET AND/OR IN ANY OTHER MEDIA PLATFORM FOR PURPOSES OF ADVERTISEMENT, PROMOTION OR FUNDRAISING, AND
For more information:
Trustee Java Rogers (708) 560-1194 email@example.com
Trustee Marlon Rias (708) 704-8035 firstname.lastname@example.org