Autism Walk Online Registration

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Registrant #1

Who are you registering? *

First Name *

Last Name *

Email Address *

Confirm Email *

Create Password *

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Confirm Password *

Date of Birth

Used for age group calculations

Phone *

Valid formats include: 000-000-0000 or 0000000000

Street Address *

Country *

Zip Code *

City *

State *

Choose Your Walk *

Autism Walk

$0.00

(Group Pricing)

Waiver

I understand that I am solely responsible for my health and safety, and acknowledge that I am physically capable of participating in any fundraising or awareness activity I undertake. If I am injured as a participant in an event, I agree to assume all risks, and to release and hold harmless Autism Alliance of Northeastern NY and its officers and representatives. I am aware that this is a RELEASE OF LIABILITY and a contract between me and the persons and entities mentioned above.

I agree to allow Autism Alliance of Northeastern NY the use of my name and likeness in connection with my fundraiser, for any purpose related to advertising or promotion in all forms of media.

If the participant is under 18 years of age at the time of registration, the participant's parent or legal guardian must review and agree to this Waiver and Release. The parent or legal guardian understands and consents to its terms, and authorizes the participation of the registrant by his/her acceptance below.

By checking this box, I agree to the waiver and that I am 18 or older, or that I have the authority to register these participants and agree to the waiver for them, and agree to the Privacy Policy.

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Autism Walk

Registrant #1

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Choose Your Walk *

Waiver

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