LAOH ST. BRIGID DIVISION 39 KATE'S WAY 6th Annual Breast Cancer Awareness Walk

LAOH ST. BRIGID DIVISION 39 6th Annual Breast Cancer Awareness Walk Date: May 7, 2011 Rain or Shine Time: 9:00 A.M. Registration Start Time: 10:00 AM promptly Place: Perzel Community Center Cost: $20.00 Adults 2990 St. Vincent St., 19149 $10.00 Children 6-12 includes T Shirt (St. Vincent & Battersby Streets) 5 and Under - No Charge - No T Shirt Register Early !!!! Use one form for each registrant!!! For additional information or extra forms visit our web site at: www.aoh39phila.com Registration includes a t-shirt and give-a-ways if your registration is received by April 17, 2011. Also included is a donation to local organizations for Breast Cancer Research and Support, refreshments and much more. Local Hospitals and Support Centers will have representatives available with educational materials and to answer your questions. Remembrance Wall - Bring a picture of your loved one to hang on our remembrance wall. We will remember them by reading their name during the ceremony before the walk begins. Send your completed Form and Payment by April 17, 2011 to: Kass Milligan – LAOH BCA Walk - 3337 Sheffield St. - Phila., Pa. 19136 Make checks payable to: LAOH DIVISION 39 BCA Walk – please print your information below, cut along dotted line and mail bottom portion. Keep the top portion for your information. ------------------------------------------------------------------------------------------------------------------------------------------------ Name: _______________________________________ Phone #_______________________ Street Address: ______________________________________________________________ City: ____________________________________State: ___________ Zip: ______________ Email: ______________________________________ (for notification of future info on our walk) In consideration of being permitted to participate in the Breast Cancer Awareness Walk, I hereby for myself, my heirs, and personal representatives assume any and all risks, which might be associated with the event. I further waive, release, discharge, and covenant not to sue the sponsors, organizers, volunteers, the AOH/LAOH and their representatives, or successors and assigns, for any and all injuries or damages of any kind whatsoever suffered as a result of taking part in the Breast Cancer Awareness Walk and any related activities. I also agree to the use of any photo, film or videotape of the event for any purposes. Signature: _____________________________________________________ Signature of Parent for children under 18 years old: □ _____________________________________________________________ Shirt Size: please circle one: S M L XL XXL Child’s Shirt Size: Medium (10-12) Only Paid $__________ Check / Cash