REGISTRATION FORM

Please complete and mail, with a check payable to DSNWV, to: 

DSNWV Buddy Walk Registration   P.O. Box 7102  Cross Lanes, WV 25356

Pre-registered walker registrations must be received by October 5, 2007.
Registration accepted through Walk Day, however T-Shirt availability cannot be guaranteed.

Name:

Address:

City: State: Zip:

Phone: E-Mail:

Name of Buddy (person with DS) walking in honor of:

Buddies walk free and also receive a T-shirt!

Team name (if applicable):___________________________

ÿ Walker/Team member     $8  Pre-registration $10  Walk Day

ÿ Family (up to 2 adults, 2 children)  $25 ($8 each additional person)

Walkers' names:

1.	4.
2.	5.
3.	6.

ÿ  Yes, we plan to come to the reception on Friday, Oct 12th  # attending:

ÿ I can not participate in the walk, but please accept my donation to support inclusion and acceptance of people with Down syndrome: $

ÿ  I have enclosed a check for my registration or donation

ÿ  Please contact me to volunteer on the day of the event

Please circle T-shirt size(s)

Adult:        S        M       L      XL          XXL (please add $2)

Youth:       S        M       L  

Toddler:   2T      4T

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 National Down Syndrome Society or the Down syndrome Network of WV, their officers, employees, sponsors, organizers, volunteers or other representative or their successors and assigns, for any and all injuries or damages of any kind whatsoever suffered by myself and/or my minor child as a result of taking part in the event and any related activities.  I also authorize the use by NDSS/DSNWV of any photo, film or videotape taken of me or my minor child at the event for any purpose.

Signature:               Date:

THIS REGISTRATION IS NOT VALID UNLESS SIGNED