Youth Anti-Gun Violence Peace Walk | Pathway Resource Center Indianapolis

Youth Anti-Gun Violence Peace Walk Registration Form

Full Name

Zip Code

Participant Age

Phone

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

RELEASE, WAIVER OF LIABILITY AND INDEMNIFICATION General Consent: By checking the radio button below, I hereby agree to release and hold harmless Pathway to the Future Learning Center, Inc. DBA Pathway Resource Center, Inc. and its affiliates. TRANSPORTATION WAIVER: I hereby grant permission for myself/my child to be transported by Pathway Resource Center, Inc.'s Driven 2 Success program shuttle bus from the event location back to my/their car. I release and hold harmless Pathway Resource Center, Inc., its officers, employees, and agents from any and all liability, claims, or demands arising from or in connection with the transportation provided. MEDIA RELEASE I grant to Pathway Resource Center, Inc. the exclusive right to use photograph/video or film likeness in media and promotional materials.

Yes, I have read the above waiver

Participant Signature

Date

Please provide Parent/Guardian information and signature below if participant is under 18.

Parent/Guardian Name

Parent/Guardian Email

Parent/Guardian Phone

Parent/Guardian Signature

Date

Thanks for registering. See you there!