1. Waiver : In consideration of me and/or my minor child being permitted to participate in the Buddy Walk, I hereby--for myself, my heirs and personal representatives--assume any and all risks which might be associated with the event. I further waive, release, discharge and covenant not to sue the Down Syndrome Association of Northwest Indiana, its officers, employees, sponsors, organizers, volunteers or other representatives or their successors and assigns, for any and all injuries or damages of any kind whatsoever suffered by myself and/or minor child as a result of taking part in the events and any related activities. I also authorize the use by Down Syndrome Association of Northwest Indiana of any photo, film or videotape taken of me or my minor child at the event for any purpose. Sign______________________________________________________ Date _______________________________________ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Note: You can also register on-line at www.dsaofnwi.org ________________________________________________________________________________________________________ Name or Companywww.dsaofnwi.org ________________________________________________________________________________________________________ Street AddressCityStateZip ________________________________________________________________________________________________________ Daytime PhoneEmail Down Syndrome Association of Northwest Indiana 2012 Buddy Walk® Sunday, October 14 Walk Begins at 12:00 PM, Check in 10:30 AM Lake County Fairgrounds 899 S. Court Street Crown Point, Indiana Questions? Email: buddywalk@dsaofnwi.org _____ Yes! I will promote appreciation and inclusion of people with Down syndrome in this One Mile Walk. Registration donation includes a Buddy Walk T-Shirt, Event Tag, Post-Walk Party with food and drink provided, and support for local programs and national advocacy initiatives. Registration Donation:Number of persons with Down Syndrome:____ FREE Number of Adult Walkers (13 yrs +)____ x $20 =_______ Number of Children Walkers (12 yrs & under)____ x $10 = _______ Size/ Number of T-Shirts:Adult Sizes:_____SChild Sizes:_____ XS 2-4 _____M_____ S 6-8 _____L_____ M 10-12 _____ XL_____ L 12-14 _____XXL _______ XXXL I will pick up our t-shirts at the Crown Point location ____ or the Highland office location ____. I am walking on a team for ***:____________________________ Team Name:__________________________________ (** If you are the parent of a person with Down Syndrome, please send via e-mail or fiscal mail a photo of them for your event tag(s). Check-In begins at 10:30 AM NOTE: IF YOU DO NOT PRE-REGISTER YOU ARE NOT GUARANTEED A T-SHIRT. Registration: $25 per walker on the day of event I have enclosed my check, made payable to DSA of NWI, for registration and/or donation. Please mail your donation and this registration form before September 6, 2012 to: Down Syndrome Association of Northwest Indiana Buddy Walk Registration 2927 Jewett Avenue Highland, IN 46322 ______ No, I cannot participate in the Buddy Walk but Please accept my donation to the Buddy Walk. Donation*: $_________ *A portion of your contribution may be tax deductible as the group is a charitable organization under 501(c)(3). ______ Please contact me to volunteer. ______My company has matching funds. Attached is a matching funds gift form.