Walk for Our Local Youth


	Walk To The Future Walk For Our Local Youth Silicon Valley We Believe in Youth Saturday September 17, 2011, Alviso California (North San Jose)

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Valley Medical Center Foundation & Firehouse Community Development Corporation
& Santa Visits Alviso Foundation in conjunction with Santa Clara County Supervisor Dave Cortese

Proudly Present .. A multi-thousand person Walk For Local Youth of the Bay Area
Join us to walk for many youth causes.

Join us in Alviso for a fundraiser walk to raise money to fight for our youth. Walker registration is as follows until registration closes September 16 or until the walk is full, whichever comes first. Space is limited:

Under 12 years = FREE
12 years to 17 years = $5
18 years to 62 years = $20
63+ years = $5

Note that this is a multi-step process. You will need to fill out this Once your online registration is complete, you will be able to raise pledges online from family/friends/neighbors/coworkers/anybody you know. Pledges raised online will be credited to your name.

On Walk Day, Saturday September 17, 2011....
Arrive no later than 8:30 am.
Walk kicks off 9 am from the Jubilee Church. Walk is 3 miles.
On-site registration at Jubilee Church opens at 7:30 am.
Light snacks will be available to walkers.
Arrive at the spectacular "Day on the Bay" in the Alviso Marina about 10:30am

Don't know how to raise money? Believe us, it's easier than you think to raise money for causes in which you believe. Read this website first, for hints on getting started: http://www.regathon.com/walkforyouth/hints.htm Then sign up below, and we will hold your hand through your fundraising journey.

To register as a Walker, please fill out this form. *required fields
Note: This form is to register individual walkers.
All walkers must be registered to be able to raise pledges for their favorite nonprofit.
To register a team or to register many people, please contact us: walkforyouth@regathon.com

*Select the nonprofit group for which you will be walking.

Proceeds from pledges you raise will go directly to this group.
Can't decide? Check here for info on the beneficiaries.

Walker's Name*

First Name	Last Name

Email*

Enter Email Again*

Phone*

ext:
Don't forget your area code

Cell Phone

So we can contact you during the walk. Please include area code.

Street Address*

City*

State*

Zip*

Gender

Male

Female

Your Birthdate

Your Age

years

Under 12 years = FREE
12 years to 17 years = $5
18 years to 62 years = $20
63+ years = $5

How will you be paying your walker registration fee?

	I will pay by Credit Card through the Walk For Youth PayPal Account
	I will mail a Check

Note: All payments must be received before your registration is complete.

PLEASE pay your payment as soon as you can so we don't have to spend limited staff time sending payment reminders. Thank you!

Team Name

If you are walking with a team, please type the name of the team here.

If you do not yet have a team name, you can continue registering, then just ask us to add a team name later....

How did you hear of Walk for Our Local Youth?

Other:

Have you walked in a Walk For Youth before?

	Yes, I have walked with Walk for Youth before
	No, this is my first year walking with Walk for Youth

The Route
Start at Jubilee Church, 105 Nortech Pkwy, Alviso, California
Meander through Alviso, checking out the historic sights.
Wind up at the Alviso Marina, Hope St and Mill St
for Supervisor Dave Cortese's fabuloua "Day on the Bay" from 10am-4pm

Does your employer have a matching gift program?

	Yes
	No

If yes, please contact your employer for a matching funds application and forward it to us.

Who is your employer?

For matching funds purposes only.

What is your T-Shirt size? *

Adult Sizes:Small Medium Large 1-X 2-X
Children Sizes:2-4 6-8 10-12 14-16

Emergency Contact Info

Who should we contact in case of an emergency? *

Emergency Contact Name

How is this person related to you? *

(Mother, Father, friend, co-woker, etc)

Emergency Contact Phone Number *

(Please include the area code)

Do you want to make your pledge in honor of, or in memory of, anybody special?
Do you have a brief story to tell about the person? Type it here:

Example: I am walking for my sister Mildred who was shot while walking home from school.

Any other comments for the Walk For Youth Staff?

RELEASE OF LIABILITY - READ BEFORE SIGNING

In consideration of being allowed to participate in any way in the Walk For Youth walk, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that:

1.    The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,

2.    I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,

3.    I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Company immediately: and,

4.    I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS Walk For Youth, their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity ("Releasees"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE
(UNDER AGE 18 AT TIME OF REGISTRATION)

This is to certify that I, as a parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my child and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.

Type your full name here if you are in agreement with the liability release:

18 or under requires parent/guardian name.

MEDIA RELEASE

I hearby authorize and give my full consent to Walk for Youth to copyright and/or publish any and all photographs, videotapes, and/or film in which I appear while attending Walk for Youth events/activities. I further agree that Walk for Youth may transfer, or cause to be used these photographs, videotapes, or films for any exhibitions, public displays, publications, commercials, art and advertising purposes and television programs without limitations or reservations:

Type your full name here if you are in agreement with the media release:

18 or under requires parent/guardian name.

Type the number below into the box below (spam prevention):
8923 -->Type that number here-->

Please verify that all information above is correct before you click submit.

Registration cost per walker

Under 6 years = FREE
7 years to 16 years = $5
17 years to 62 years = $20
63+ years = $5

If the race should be cancelled, delayed or postponed for any reason outside the direct control of the Race Director (inclement weather; Local, State, or National emergency; or conditions on the race course), refunds will not be given, but arrangements will be made for participants to pick up their shirts and runner swag bag.

Once you submit your application, you can pay by one of 3 methods.

1. Pay by logging into your PayPal account

2. Pay with a credit card without using a PayPal account
* After clicking below, simply fill in your information on the left side of the page.
* If you do not see fields to fill out, click the "Continue" link on the bottom left side of the page (under "Don't have a PayPal Account?").

3. Pay by check.

Questions? Call Walk For Youth 408.885.5299 (10am to 3pm, M-F)

Questions? Email Walk for Youth walkforyouth@regathon.com

Beneficiaries Include
- Valley Medical Center Foundation
- Firehouse Community Development Corporation
- Santa Visits Alviso Foundation
- Many many more