Event Registration 1-Sponsorship 2

2008 5K Empowerment Walk Registration Form

This form is being submitted on a secure connection. It is encrypted for privacy using 128 bit encryption technology to protect your privacy.

Please complete the following information to register as an individual or team walker.

Items with*are required fields.

Your First Name *

Your Last Name *

Address *

City *

State *

Zip *

Home Phone Number including area code*

Work Phone Number including area code

Please Call me at

Home

Office

Select Your Team

Optional - Team Name

No, I cannot attend but I would like to contribute

Registration Fee $25.00 Per Person prior to May 1.
After May 1, $30.00. Children under 10 free.

Non-refundable entry fee includes Race T-shirt

You may pay with a credit card by entering the information into the form or send a check to the address below.

First Name

Last Name

Exp. Month

(mm/yyyy)

Card Type

Card Number

Number of Participants

Additional donation (Optional)

Total Amount to Be Charged

Healing Odyssey
23591 El Toro Rd, Suite 214
Lake Forest, CA 92630

WAIVER AND RELEASE OF LIABILITY

By registering for The Healing Odyssey Empowerment Walk, participant agrees to the following Waiver and Release of liablitiy. In consideration for being permitted to participate in the Empowerment Walk/Run in Huntington Beach, California, I agree to assume all risk and to release and hold harmless Healing Odyssey Inc., its affiliates, beneficiaries, sponsors, directors, officers and agents, and all other persons and entities associated with this event, who might be liable to me through negligence or any other cause in connection with this event, by running, walking or serving as a volunteer. I may be exposed to various hazards, and I am aware of and appreciate the risks that may result. I agree to accept all risks of injury or death and I am voluntarily participating in this event with full knowledge of these risks. I have read and understand this Waiver and Release of Liability and agree that it is binding upon me, my heirs and assigns.