Contact Us: (317) 890-9817
August 15th Annual Far Eastside Community Peace Walk Flyer Registration Form:
First & Last Name:
1. If under 18 a parent/legal must consent & sign form to include DOB
2. Do you know someone who was injured by being shot?
3. Do you know someone who died from being shot?
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. 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
Thanks for submitting!