Participant

Registration Form

Instructions: 1. Register online at http://www.firstgiving.com/ammanimman/a-walk-for-water-2012-lake-frank-md or complete the registration form b elow and return it to your A mman Imman school rep or the A I office (see address b elow). Please fill out a separate form for each person. All registrations received by May 4, that raise a minimum of $50, will include a t-shirt, if indicated below. 2. NEW FOR 2012! Special Friendship Exchange for children. From 9 a m 10 a m on the rally field at Lake Frank. th Low Registration Fee. Pre-registration is $5/person until May 4. $10/person after May 4 . Onsite registration is $15 Achievable fundraising target. Each participant is requested to raise at least $50. 3. Collect sponsorships using the Sponsorship Donation Form. You can a lso create an online fundraising page at http://www.firstgiving.com/ammanimman. Click Start Fundraising and choose the Lake Frank Walk. Ask your f riends, family and neighbors to sponsor you. Sponsorship Forms and collected donations should b e mailed to the Amman Imman office by May 12, o r brought to the event. Checks should be made payable to Amman Imman. 4. Questions? Call 240-418-1143, o r email info@ammanimman.org. When: May 12. C heck-in: 9 a m. Rally: 10 a m. Walk to follow. Length of Walk: approx 3.25 m iles Where: Lake Frank, Derwood, Maryland(rain or shine) What: Participants will walk the 3.25 m iles around the lake, rain o r shine. A ll children must be accompanied by an adult chaperone. We regret t hat t he trail is not handicap accessible nor appropriate for strollers. - - - - - - - - - -- - - - - - - - - -- - - - - - - - - -- - - - - - - - - - Detach here and f ill in t he registration form below - - - - - - - - - -- - - - - - - - - -- - - - - - - - Name of sponsoring School o r Organization (if any):_____________________________________________________________________ First Name:_____________________________ Last Name:_______________________________ DOB: ____________ A ge: _________ Address:______________________________________________ City: ________________________________________ State ______ Zip:_____________ Phone:___________________________ Email: _____________________________ ___I am registering as an individual. Enclosed is my registration fee. ___ $5 until May 4 ___ $10 after May 4 ___ $15 onsite ___ check or ___ cash ___ credit card payable to Amman Imman _____ In lieu of attending, enclosed is my donation of $ __________ Each participant registered by May 4 who raises at least $50 will receive an official A Walk for Water T-shirt. Please Circle: Youth T-Shirt Sizes: S M L XL Adult T-Shirt Sizes: S M L XL ___ No thanks, I dont w ant a t-shirt Media Release: I give permission for the use of my name and image (or my childs name and image) in any broadcast, telecast, and/or print media of this event. Please choose one : ___Yes, I give permission for my name & i mage ____I give permission only for my image, ___No, I do not give my permission
PLEASE READ AND SIGN WAIVER. RETURN REGISTRATION FORM and CHECK PAYABLE TO Amman Imman to the address below, or hand in to your school rep. In c onsideration of being allowed to participate in A Walk For Water (hereinafter the Event), and intending to be l egally bound, I hereby for myself, my heirs, executors, administrators and assigns, waive and release all rights and claims for damages which I may have now or in the future against Amman Imman Water is Life, Inc. and its officers, directors, employees, agents and affiliates, a nd their respective heirs and l egal representatives (collectively, Amman Imman), arising out of or relating in any way to the Event, including all claims for personal i njuries a nd/or property damage sustained by me before, during, or after said Event, w hether caused or alleged to be caused in whole or in part by the negligence of Amman Imman or otherwise. I also hereby covenant not to sue Amman Imman for a ny matter arising out of or connected with the Event. I recognize that the Event involves activities that are physically demanding and w hich carry a possibility of s erious injury, including permanent disability or death. I hereby warrant a nd represent to Amman Imman: (a) that I am physically and emotionally fit a nd sufficiently trained to participate in a nd c omplete the Event; (b) that I k nowingly and v oluntarily assume all risk and responsibility whatsoever associated with my participation in the Event; and ( c) that I have carefully read and fully understand this Waiver a nd R elease and willingly agree to all of the conditions and obligations set forth herein. _____ I a m the legal guardian of the minor participating (the Participant) identified a bove. I certify that I consent to his/her participation in the event. I have read the foregoing waiver agreement, and I hereby agree on behalf of myself a nd the Participant to all of its terms.
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____________________________________________________________________________________________________________ Participants/Legal Guardians Printed Name Participants/Legal Guardians Signature Date

Amman Imman: W ater Is L ife, 7036 Strathmore Street, Suite 111, Chevy Chase, Bethesda, MD 20815 www.ammanimman.org * info@ammanimman.org