EACH PARTICIPANT MUST COMPLETE AND SIGN A FORM LIFESAVERS WALK AT THE EVANSVILLE STATE HOSPITAL SATURDAY, August 27, 2016 Registration and t-shirt pickup 8:00-9:00 AM Walk begins at 9:15 am. A one mile walk to promote suicide awareness, education, and prevention sponsored by The Southwestern Indiana Suicide Prevention Coalition, Deaconess Cross Pointe, Deaconess Hospital, St. Mary’s, Southwestern Healthcare, Inc. , Brentwood Meadows, & Within Sight. All Proceeds from the LifeSavers’ Walk are used in the tri-state community to provide funding for the suicide prevention activities sponsored by the Southwestern Indiana Suicide Prevention Coalition. Please print clearly. One participant per registration form. Entry form may be reproduced. LAST NAME__________________________________________ FIRST NAME____________________________________ WALKING IN MEMORY OF or TEAM NAME_____________________________________________________________________________________ STREET ADDRESS___________________________________________________________________________________________________ CITY_________________________________________ STATE_____________ ZIP_______________ EVENING PHONE__________________________________________________ DAYTIME PHONE________________________________________________ E-MAIL ADDRESS _________________________________________________________________ SEX M F DOB _______________________ This year, we will be offering the semi-colon project jewelry for purchase at the Walk with prices ranging from $.10 - $15. We will offer yard signs to be decorated in memory of your loved one. If you would like to pick your sign up ahead of time, please contact Janie Chappell at the numbers below. Or you may bring your pictures or other memorabilia to decorate it prior to the walk. For the safety of all participants, inline skates are not permitted. And pets are discouraged from participating in this event. Thank you for your cooperation. Registration – Adult…………………………….……..…$25 Child (12 and under) or Senior (65 and over)……….$10 I am unable to participate in the walk but would like to make a donation of………..…………….. _________ TOTAL Enclosed $ ________ All proceeds will be used to promote suicide awareness, education, and prevention activities in our Tri-State area. You may also register online at www.deaconess.com/lifesavers WALK WAIVER AND RELEASE All registrants must sign. Parents must sign for minors. I understand that my consent to these provisions is given in consideration of the acceptance of this registration and for being permitted to participate in this event. I KNOW THAT THIS EVENT IS A POTENTIALLY HAZARDOUS ACTIVITY AND I HEREBY ASSUME FULL AND COMPLETE RESPONSIBILITY FOR ANY INJURY OR ACCIDENT WHICH MAY OCCUR DURING MY PREPARATION FOR, PARTICIPATION IN, OR WHILE ON THE PREMISES OF, THIS EVENT, AND I, FOR MYSELF, MY EXECUTORS, HEIRS, ASSIGNEES, AND ANYONE ELSE WHO MIGHT CLAIM ON MY BEHALF, HEREBY WAIVE, RELEASE, DISCHARGE, HOLD HARMLESS AND COVENANT NOT TO SUE THE SOUTHWESTERN INDIANA SUICIDE PREVENTION COALITION, DEACONESS CROSS POINTE, AND ALL WALK SPONSORS, VOLUNTEERS, AGENCIES, PARENTS, SUBSIDIARIES, AFFILIATES AND BENEFICIARIES, AND THEIR AGENTS AND EMPLOYEES, AND ALL OTHER PERSONS OR ENTITIES ASSOCIATED WITH THIS EVENT JOINTLY AND SEVERALLY (THE “RELEASEES’) FROM AND AGAINST ANY AND ALL ACTIONS, INJURIES, DEMANDS, LOSSES, LIABILITIES, DAMAGES, CLAIMS OR EXPENSES OF WHATEVER KIND AND NATURE, FORESEEN OR UNFORESEEN, KNOWN OR UNKNOWN, INCLUDING ATTORNEY FEES, WHICH AT ANY TIME I MAY HAVE ARISING OUT OF MY PREPARATION FOR OR PARTICIPATION IN THIS EVENT, INCLUDING PERSONAL INJURY, DEATH, PROPERTY DAMAGE OR OTHER DAMAGE SUFFERED BY ME OR OTHERS, WHETHER THE SAME BE CAUSED BY TRIPS, FALLS, CONTACT WITH PARTICIPANTS, CONDITIONS OF THE COURSE, NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I am a voluntary participant in this event and attest and verify that I am in good physical condition and sufficiently trained to participate. If I do not follow all the rules of this event, I understand that I may be removed from the walk. I give my full permission to the Southwestern Indiana Suicide Prevention Coalition, all Walk sponsors and all of the above-defined Releasees, to use my likeness, including any photographs, videotapes, audiotapes, recordings or any other record of me that are made during the course of this event for any purpose without compensation. I acknowledge that inclement weather is a possibility and that such weather could result in the abbreviation or cancellation of the Walk. In such event, I agree that no refunds, full or partial, will be given and my entry fee will be donated to the Southwestern Indiana Suicide Prevention Coalition. T-shirts not guaranteed unless pre-registered. Signature: __________________________________ (All applications must be signed) __________________________________ (Parent or guardian must sign if participant is under the age of 18) Date: ________________________________ EACH PARTICIPANT MUST COMPLETE AND SIGN A FORM Make check or money order payable to: Deaconess Cross Pointe - LifeSavers Walk Deliver or Mail to: Deaconess Cross Pointe / LifeSavers Walk Attn: Janie Chappell 7200 East Indiana Street Evansville, IN 47715 812.471.4521 or 800.947.6789 janie.chappell@deaconess.com