Type of Registration (check one):

Pre-Registered (I have mailed, phoned, faxed, or emailed my registration prior to today)
Initial Registration (this is my only registration for the Walkathon)
Donation Only (I am making a donation only I will not walk)
 

First Name

Last Name

Address

City, State Zip

,

Day Phone

Evening Phone

Email

Your confirmation and walkathon information will be sent to the email address you enter above

How did you hear about the NAMI walk?

Picked up a brochure
NAMI web site
Radio Station
For this option, please enter the radio station's call letters:

Friend or Family
Other please identify:

Waiver of responsibility:

Waiver of Responsibility: In signing this waiver and release, I acknowledge that I understand its intent, and I for myself, my heirs, executors, administrators and representatives, do hereby agree and will absolve and hold harmless the National Alliance on Mental Illness, the NAMI McHenry County affiliate, corporate sponsors, cooperating organizations and any other parties connected with this event in any way, together with their respective successors, and assigns (the Sponsors) singly and collectively, from and against any blame whatsoever, which may result from or be connected in any way to my participation in the NAMI McHenry County affiliate walk. In addition to the absolute and unqualified release from all liability, I hereby represent that I am physically capable of participation in this event, and I will observe all applicable traffic and event rules, and that I will conduct myself in a safe and prudent manner while participating in the event and I hereby absolve and hold harmless the Sponsors from any damage I may sustain because of any breach of these representations. I understand that the National Alliance on Mental Illness, and the NAMI McHenry County affiliate, reserves the right to refuse or dismiss anyone that may cause any disturbance or hindrance in any manner that could jeopardize the success of the walk. I hereby consent to and permit emergency treatment in the event of injury or illness while participating in this event. I also give permission to the National Alliance on Mental Illness, and the NAMI McHenry County affiliate to use my name and any photography taken of me during the event in any promotional materials.

I certify that by clicking submit below I am submitting my registration for the Walkathon and have read the waiver and release above and understand its significance.