Home

People Who Care

Contact Us

  
Support
Services

Education
&Resources

News &
Information

Calendar
Coming
Events		 Get
Involved

Walk to Remember 2009

 
 

Registration

Salem Poster

Albany Poster

Quilt Raffle

Sponsorship Packet

Health & Resource Fair

Team Information

Silent Auction 

  

Instructions:
After filling out this registration form submit it to AlzNet by clicking on "Submit" at the bottom of the form.
If you submit your registration through the website, you will be asked to sign the waiver on the day of the walk.

If you do not wish to submit this form online:
You may print and sign this form and FAX it to 503-364-8102 or mail it to P.O. Box 12701, Salem, Or. 97309

Click Here, or the link at the bottom of the page to print a registration form
 
TEAM CAPTAINS: Do not fill out or submit this form online. Go to the Team Information page to get the forms you need.

TEAM MEMBERS: Do not fill out or submit this form online. Print this form here, or with the link at the bottom of the page and turn it in to your team captain.

  
 

My goal is to raise $ for Alzheimer's programs and services.

Name:

Address:

City:  State:  Zip:

Phone Day:  Evening:

Email:
Male              Female                Age:

Employer/School:

My company has a matching gift program Yes No

Company:

I will be walking at Albany 11/7 Salem 10/3

I will walk as
Team Captain Team Member Individual

If you are on a team, please complete the following:

Team Name:

Representing (name of organization):

Captain's Name:

I am walking in honor of:

Please send me the following information:
 AlzNet programs and services

Walk or other volunteer opportunities

Information on forming a walk team

Brochures (indicate quantity)

Posters (indicate quantity)

I am unable to walk, and I would like to make a contribution:

Enclosed is my donation of  $200 $100

$50 Other Amount $

Please make checks payable to AlzNet

 

 

Waiver and Release of Liability
I hereby waive all claims against the Alzheimer’s Network of Oregon, sponsors, or any personnel for any injury I might suffer in this event. I attest that I am physically fit and prepared for this event. I grant full permission for organizers to use photographs of me and quotations from me in legitimate accounts and promotions of this event. 

Signature:_________________________________ 

Date_____________________________________

(Parent or guardian’s signature if walker is under 18 years of age)



Click Here To Print a Registration Form
 
 

This site is designed and maintained by SafeTnet: Making Your Computer A Safe Place To Work And Play!
 Copyright 2005 The Alzheimer's Network of Oregon