2020 Diabetes Foundation of Mississippi Walk Registration

*Required Field

 

Contact Information

Title: * --Select--Dr.Dr. and Dr.Dr. and Mrs.Mr.Mr. and Dr.Mr. and Mr.Mr. and Mrs.Mrs.Mrs. and Mrs.Ms.RabbiRev.The Hon.Pastor
First Name*
Last Name*
Email Address*
Address*
Address Line 2
City*
State*
Zip*
Country*
Phone Number*

Registration Information

• Date 04/26/24

Walk Location Choose Your Walk Location Gulfport -Sat.- Sept. 12 Meridian - Sun. - Oct. 4 Jackson - Sun. - Oct. 11 Hattiesburg - Sun. - Oct. 18 Columbus - Sun. - Oct. 25 Oxford - Sun. Nov. 1 *

Walk Team and/or Team Captain Name


• Donation: Suggested Minimum Donation $25.00 Walk T-Shirt $50.00 Walk T-Shirt & Gift Certificate $100.00
• Once you register, we encourage you to go to the Foundation's page on Crowdrise and set up your team donation page. Walkers who raise more than $2500 will have their name entered into the Grand Prize Drawing. T-shirts will be distributed at the walk to walkers who raise $50 or more.
  
  I waive my gift. Please use my entire donation for your programs and services!    
  YouthS     YM     YL     AdultS     M     L     XL     2XL     3X

  Release and Indemnification   

  I understand that Mississippi's Walk for Diabetes involves physical activity (walking, running, etc.), which may include risks such as, but not limited to, falls, effects of weather, traffic and conditions of the road, and interactions with other participants. In consideration of being allowed to participate in this event, I hereby expressly assume all risks for myself including personal injury, arising in any way from my participation in the Walk for Diabetes and related activities.

  It is my responsibly to dress appropriately and bring any medical equipment or medications that I might require. I understand that although route maps, rest stops, refreshments, first aid and other assistance may be available during this event, I am solely responsible for my own health and safety. I agree to ask for assistance if I experience any symptoms or conditions which would make it difficult or unsafe to continue in the event.

  I agree for myself, my heirs, executors and administrators, not to sue and to release, indemnify and hold harmless, the Diabetes Foundation of Mississippi, Southern Farm Bureau Life Insurance Company and Association, their officers, directors, volunteers, and employees, and all other sponsoring businesses and organizations and their agents and employees, from all liability, claims, demands and causes of action whatsoever, arising out of my participation in this event and related activities -- whether it results from the negligence of any of the above or from any other cause.

  This release and indemnification agreement shall be as broad and inclusive as is permitted by the State of Mississippi or city in which the event is conducted. If any portion of this release shall be held invalid under the laws of Mississippi, those parts not held invalid shall continue in full force and effect.

  (If you are registering for a minor): I am the legal Guardian of the Walk Participant, and hereby consent to his/her participation in Mississippi's Walk for Diabetes. I have read the foregoing release and indemnification agreement, and I hereby agree to its terms on behalf of myself and Participant.

      I Agree  

      I will sign a paper waiver at registration at my walk.  

      I cannot attend the walk but wish to support my team/DFM.  

Credit Card Information

• Card Type Visa MasterCard American Express Discover
• Name as on Card*
• Same As Contact
• Card Billing Address*
• Card Billing Zip*
• Card Number*
• Card Expiration Date* MMYY
• Card ID (CVV2/CID) Number*
  [What is the Card ID?]