Monroe County Breast Cancer Awareness Walk Registration

Registrant Information

1. Please enter your contact information:

First Name *This question is required.

Last Name *This question is required.

Phone Number *This question is required.

Address (Street, City, ZIP Code, State) *This question is required.

Email Address This question requires a valid email address.

2. How old are you? *This question is required.

3. Are you a breast cancer survivor?

How many years have passed since your diagnosis?

4. IN CONSIDERATION FOR BEING ALLOWED TO PARTICIPATEIN THIS PROGRAM, I AGREETO HOLD HARMLESS MONROE COUNTY HEALTH DEPARTMENT, ITS AFFILIATES, ITS STAFF MEMBERS AND CONTRACT
INSTRUCTORS FROM LIABILITY AND ALL CLAIMS, SUITS, LOSSES, OR RELATED CAUSES OF ACTIONS OR DAMAGES, INCLUDING BUT NOTLIMITED TO, SUCH CLAIMS THAT MAY RESULTIN
INJURY OR DEATH, ACCIDENTAL OR OTHERWISE, DURING OR ARISING FROM MY (OR MY CHILD'S) PARTICIPATION IN THIS PROGRAM. AS A RESULT OF PARTICIPATING IN THIS
PROGRAM, I/MY CHILD MAY BE PHOTOGRAPHED. I AUTHORIZE MONROE COUNTY HEALTH DEPARTMENT TO SUBMIT PHOTOGRAPHS TO BE PUBLISHED IN THE NEWSPAPER AND/OR SOCIAL MEDIA.

I consent to the statement above. I am 18 years of age or older and I agree to participate, or agree on behalf of my children who are under 18. *This question is required.

Clear

Signature of

Thank you for completing the registration! If you are interested in a shirt or an In Memory Of/In Honor Of sign, please contact the Monroe County Press/Tompkinsville News Office.