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Bristol Central High School-May 16, 2009 (Rain date 5/17) Registration: 9am-10am Walk: 10am-12pm Sponsored by the BCHS Interact Club

Name:_________________Parent Name if Under 18 ________________ Parent Signature if registrant is under 18__________________________ Address:_______________________________________ City:______________State:______ Zip Code:_________ Email:_______________________Daytime Phone:_________________ Please Select Adult Shirt Size: Shirt included with early registration postmarked by 4/27. XXL XL L M S Entry Fees: _____ Registrations@$20 _____ Early Registration: $20 _____ Registrations@$22 _____ Registration: Postmarked after April 27th - $22 I am unable to participate in the walk but would like to make a donation Please make checks payable to: Total Enclosed: $________ “Tyler James Gingery Memorial Walk” Please mail completed registration to : Sean and Michele Gingery 100 Pondview Lane, Bristol, CT 06010 Thank you for participating in the “Tyler James Gingery Memorial Walk”. Your contribution will fund additional research to find a cure for Hypertrophic Cardiomyopathy. Waiver: I agree to participate in the “Tyler James Gingery Memorial Walk”. In consideration of my entry, I do hereby waive, release and forever discharge any and all rights and claims which I (or my child) may have or which hereafter accrue to me against the sponsors for any and all injuries suffered by me (or my child) while participating in the event and do hereby certify that I (or my child) am physically able to participate in this event. Signature:_____________________________________________________Date:_________________________________

Tyler James Gingery Memorial Walk Registration  

Registration form for the Tyler James Gingery Memorial Walk

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