Concho Valley Rape Crisis Center
Concho Valley Rape Crisis Center
Help, Hope, Healing
36 W. Beauregard, Ste. B-100
WALK A MILE IN HER SHOES
REGISTRATION FORM
When: Saturday, April 25, 2015
Registration opens at 9:30 am
San Angelo, TX 76903
Phone: 325-655-2000
Fax: 325-655-6439
Email: [email protected]
Website: http://cv-rcc.org
Walk begins at 10:00 am
Where: Tom Green County Courthouse
112 W. Beauregard
STEP 1: Team (please print clearly)
Team Captain Name: _________________________________
Organization Name: __________________________________
Ask friends, neighbors, colleagues, relatives, etc. to
sponsor you by donating money to the CVRCC for
the Walk a Mile in Her Shoes event. Bring money
to the march or mail it to the CVRCC before April
25th. The team that raises the most money wins an
award and prize!
Phone: ________________ Email: ______________________
Team Members and T-shirt sizes: _______________________
___________________________________________________
___________________________________________________
Cost per team is $30 and includes
5 T-shirts.
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
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Thanks to our co-sponsors:
The Student Social Work
Association
STEP 2: Walk a Mile Waiver
In consideration of my entry in the CVRCC Walk a Mile in Her Shoes® event, I for myself, my heirs, executors
and administrators waive and release any and all rights and claims for damages or injury I have or may incur
against the organizers of this even, it’s principals, its employees, all sponsors and their representatives and all
claims of damages, demands, actions whatsoever in this manner, as a result of my participation in the Walk a Mile
event, including travel to and from this event. I attest and verify that I am physically fit and have sufficiently
trained for completion of this event and have not been advised otherwise by a qualified medical person. Further, I
hereby grant permission to any and all foregoing to use my name and likeness in any broadcast, telecast, video or
print media of the event without compensation. CVRCC reserves the right to refuse participation in our Walk a
Mile event.
All entrants (parents/guardian if under 18) must sign.
Signature: _________________________________________________ Date: _____________________
Signature: _________________________________________________ Date: _____________________
Signature: _________________________________________________ Date: _____________________
Signature: _________________________________________________ Date: _____________________
Signature: _________________________________________________ Date: _____________________
Signature: _________________________________________________ Date: _____________________
Signature: _________________________________________________ Date: _____________________
Signature: _________________________________________________ Date: _____________________
Signature: _________________________________________________ Date: _____________________
Signature: _________________________________________________ Date: _____________________
Signature: _________________________________________________ Date: _____________________
Signature: _________________________________________________ Date: _____________________