Registration Form

First name

Last name

Phone

School that you are attending (Please write N/A if you are not a student)

Emergency Contact Name

Emergency Contact Number

Waiver: I waive all rights of claims that I may have against One Heart Beat March, walk officials, administrators, or any other organizations or individuals associated with this event. I attest and verify that I am physically fit for participation in this event.

I give permission to have myself appeared in any public or media coverage, including but not limited to photographs, videotapes, recordings as approved by One Heart Beat March.

Parent Signature (NOTE: If the registant is under the age of 18, a parent or legal guardian must sign below)

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