Registration Form - Centre on Philanthropy
The Bermuda Nurses Association invites you step out at the
Sunday May 20th @ 8am Starting @ Bull’s Head Car Park Registration $20 * * Part Proceeds to the Coalition for the Protection of Children Breakfast Program
To register go to racedayworld.com and select BNA Charity Walk T-Shirt Collection for first 50 to arrive Friday May 18 2pm – 4pm Employee Health Montrose Cottage, KEMH
The Bermuda Nurses Association’s Sunday May 20, 2012 @ 8am REGISTRATION FORM First Name: __________________ Last Name: __________________ Phone: ____________ Email: ____________________ Date: ____________________ Emergency contact (name):____________ Emergency contact (number): __________
Registration Fee: $20 Checks to be made payable to Bermuda Nurses Association T-Shirt pickup for first 50 on arrival on Friday May 18th between 2pm – 4pm at Employee Health Montrose Cottage, KEMH
-------------------------------------------------------------------------------------------------------------------------------WAIVER I have read, understood and accept this waiver and release and/or on behalf of any other party on whose behalf I am registering. My submission of this form shall act as my legal signature and/or the legal signature for any other party on whose behalf I am registering. I hereby represent and warrant that I have full legal authority and power to complete this event registration for myself and/or any other party on whose behalf I am registering. Furthermore, I represent and warrant that I have full legal authority to act on behalf of all registered parties and bind them under the terms and conditions set forth in this waiver and release. I certify that I and/or any other party on whose behalf I am registering am/are eighteen (18) years of age or older. Or if registering a child under eighteen (18) years of age, I certify that I am the parent or legal guardian of such child in compliance with COPPA [Children's Online Privacy Protection Act]. If registering an incapacitated and/or mentally challenged person, I certify that I am the parent or legal guardian or receiver of such person. I and/or any other party on whose behalf I am registering hereby waive and release RacedayWorld.com, race officials and other participants from claim for injuries or damages however sustained during this event. Signature ____________________________
The Bermuda Nurses Association’s Sunday May 20, 2012 @ 8am Pledger’s Name
Contact Number
Amount Pledged
Participant: ________________ Day time contact: ___________
Amount Collected
Total
Evening contact: ____________ Email: ________________
Contact the Race Organizer: Name: Karima Stevens Organization: Bermuda Nurse Association Phone: 7371030 E-mail: [email protected] Event Type - Walking Date & Time - Sunday, May 20, 2012 Address - Hamilton Registration Closing Date - Friday, May 18, 2012 4:00 PM Directions:
Registered Charity #374
Event will start and finish at Bull's Head Car Park. Route: Woodlands Road, left onto St Johns Road, right onto Berkeley road to North Shore Road, left onto St John’s Road, to Pitts Bay Road, left onto Serpentine Road, left onto Woodlands Road to Bull’s Head Car park. T-Shirt Pickup for the first 50 participants on arrival Walker may pick up supplies on Friday May 18, 2012 at Montrose Cottage, KEMH from 12 noon until 4pm and Sunday May 20, 2012 from 7:30 - 8:00 am at Bulls Head (if available). `
Sunday May 20th @ 8am Starting @ Bull’s Head Car Park Registration $20 * * Part Proceeds to the Coalition for the Protection of Children Breakfast Program
To register go to racedayworld.com and select BNA Charity Walk T-Shirt Collection for first 50 to arrive Friday May 18 2pm – 4pm Employee Health Montrose Cottage, KEMH
The Bermuda Nurses Association’s Sunday May 20, 2012 @ 8am REGISTRATION FORM First Name: __________________ Last Name: __________________ Phone: ____________ Email: ____________________ Date: ____________________ Emergency contact (name):____________ Emergency contact (number): __________
Registration Fee: $20 Checks to be made payable to Bermuda Nurses Association T-Shirt pickup for first 50 on arrival on Friday May 18th between 2pm – 4pm at Employee Health Montrose Cottage, KEMH
-------------------------------------------------------------------------------------------------------------------------------WAIVER I have read, understood and accept this waiver and release and/or on behalf of any other party on whose behalf I am registering. My submission of this form shall act as my legal signature and/or the legal signature for any other party on whose behalf I am registering. I hereby represent and warrant that I have full legal authority and power to complete this event registration for myself and/or any other party on whose behalf I am registering. Furthermore, I represent and warrant that I have full legal authority to act on behalf of all registered parties and bind them under the terms and conditions set forth in this waiver and release. I certify that I and/or any other party on whose behalf I am registering am/are eighteen (18) years of age or older. Or if registering a child under eighteen (18) years of age, I certify that I am the parent or legal guardian of such child in compliance with COPPA [Children's Online Privacy Protection Act]. If registering an incapacitated and/or mentally challenged person, I certify that I am the parent or legal guardian or receiver of such person. I and/or any other party on whose behalf I am registering hereby waive and release RacedayWorld.com, race officials and other participants from claim for injuries or damages however sustained during this event. Signature ____________________________
The Bermuda Nurses Association’s Sunday May 20, 2012 @ 8am Pledger’s Name
Contact Number
Amount Pledged
Participant: ________________ Day time contact: ___________
Amount Collected
Total
Evening contact: ____________ Email: ________________
Contact the Race Organizer: Name: Karima Stevens Organization: Bermuda Nurse Association Phone: 7371030 E-mail: [email protected] Event Type - Walking Date & Time - Sunday, May 20, 2012 Address - Hamilton Registration Closing Date - Friday, May 18, 2012 4:00 PM Directions:
Registered Charity #374
Event will start and finish at Bull's Head Car Park. Route: Woodlands Road, left onto St Johns Road, right onto Berkeley road to North Shore Road, left onto St John’s Road, to Pitts Bay Road, left onto Serpentine Road, left onto Woodlands Road to Bull’s Head Car park. T-Shirt Pickup for the first 50 participants on arrival Walker may pick up supplies on Friday May 18, 2012 at Montrose Cottage, KEMH from 12 noon until 4pm and Sunday May 20, 2012 from 7:30 - 8:00 am at Bulls Head (if available). `
