Registration Details


Name:
Address Line 1:
Address Line 2:
City:
State:
Zipcode:
Email Address:
Phone number:
Cell Phone:
Shirt Size:

Payment


The entry free is $20
* Name as it appears on Credit Card:
* Credit Card number:  
* Payment Type:
*Expiration Date: * MM:   * YY:   * CCV:

Disclaimer


Certain applications on the Roper St. Francis Healthcare web site may require users to register or to provide personal information in order to make a commerce transaction, to enter a contest, or to subscribe to a newsletter. Such personal information is not shared or sold to third parties. If you would like to be added to our mailing list or received further information from Roper St. Francis please indicate by checking the box below.



Waiver Release


I know that walking a road walk is potentially hazardous activity. I should not enter and walk unless I am medically able and properly trained. I assume the risk of participants, the effects of the weather, including high heat and humidity, and the condition of the roads, all such risks being known and appreciated by me. Furthermore, I agree to yield to all emergency vehicles. Knowing these facts, and in consideration of your acceptance of my entry, I hereby for myself, my heirs, executors, administrators, or anyone else who might claim on my behalf, covenant not to sue, and waive and release and discharge. The AIDS Walk and its affiliates, their agents, employees, officers, directors, volunteers, Roper St. Francis Healthcare, the City of Charleston, and any and all walk sponsors, their representatives and successors, from any and all claims or liability for death, personal injury, or property damage of any kind or nature whatsoever arising out of, or in the course of, my participating in this event. This release and waiver extends to all claims of every kind or nature whatsoever, foreseen or unforeseen, known sponsors and/or agents authorized by them to use any photographs, videotapes, motion pictures, recordings, or any other record of this event for any purpose. By submitting this form, you agree to the terms of this waiver release.