A Safe Place 12th Annual Walk & Shop

October 19, 2013

DONOR & VOLUNTEER FORM

(Online registration available at http://www.asafeplace2013.eventbrite.com) Please complete this form and return it with your registration fee to A Safe Place P.O. Box 23006 Oakland, CA 94623 prior to the start of the event. To receive a t-shirt, order form must be received by September 19, 2013. T-shirts and participant packets will be available for pick up at the walk event. ALL participants must submit an individual registration form to be considered for prizes.
Thank you for participating in the A SAFE PLACE 12th Annual Walk. Your contribution will directly support the Domestic And Teen Dating Violence services. Please use this form for individual registration(s) only. If you are part of a walk team, each team must complete a team registration form and indicate the team name if applicable. The Walk will start on Saturday, October 19, 2013 at the Lake Merritt Edoff Memorial Bandstand, Oakland, CA. Event-day registration starts at 8:00 am. Call 510-986-8600 with questions.

Participant registration: $10 Adult registration (shirt not included) $5 Child registration (ages 11-18) (10 years old and under free, shirt not included) Yes! I would like a t-shirt: $15 (Circle size if applicable) Small Medium Large X-Large XX-Large

TOTAL INCLUDED WITH REGISTRATION FORM: $ __________________

Interested In: Walking Company/Organization Table Volunteer for event Donating funds or resources

Donating/Volunteer Options: What time can You work/volunteer? Donations/Pledges One time contribution Monthly contribution Pledge Amount $___________ Any Time Setup 7am-9am During the event 9am-3pm Breakdown 3pm-5pm All Day Registration Decorations Water Energy Bars First Aid Clean Up Whatever Needed

Waiver and release by consent: By his/her agreement below participant assumes full responsibility for his/her physical condition and safety in this event. The participant further understands and agrees that in consideration of, as part payment for the right to participate in the 12th Annual Walk , participant assumes all risks that may occur during contestants participation in the event, including but not limited to, those associated with the forces of nature, physical injury or illness, and accidents. Participant shall indemnify all race organizers, sponsors and their agents and/or employees from any and all liability, cautions, cause of action, debts, claims, demands of any kind an nature whatsoever that may arise from or in connection with the participants involvement in this race. Participants authori zation below serves as a release and assumption of risk for all members of participants family, including minors accompanying part icipant.

Signature: ________________________________________________________ Date:_____________________________ Parent/Guardian Signature (if under 18):__________________________________ Date:________________________________