2008 EFVA EPILEPSY AWARENESS STROLL
REGISTRATION & PLEDGE FORM


NAME:_____________________________________________________________________________
ADDRESS:__________________________________________________________________________
CITY, STATE, ZIP:___________________________________________________________________
HOME PHONE #:____________________________ E-MAIL:________________________________

Free T-shirts for donations of $20 and up.

Bring this form and your donations to the registration desk on the day of the event.

If you cannot attend, mail this form and donations to: 
EFVA, PO Box 800659, UVA Medical Center, Charlottesville, VA 22908
Make all checks payable to: Epilepsy Foundation of Virginia (EFVA)

Sponsor List: Ask friends and family for donations to EFVA Epilepsy Awareness Stroll on your behalf.
All contributions are tax-deductible to the extent of the law.

SPONSOR NAME                                SPONSOR ADDRESS                                   DONATION $

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WAIVER: I, ________________________________________(Print Name) for myself, my heirs and executors in consideration of any participation in the Epilepsy Awareness Stroll, hereafter called the Event, hereby releases, holds harmless and covenants not to sue the Epilepsy Foundation of Virginia and others connected with the Event, including the Epilepsy Foundation of America, municipalities, sponsors, and their directors, officers, employees, volunteers, or agents from any claims or damages or injuries which I may have ore which I may suffer in connection to the Event. I give my consent to use my name, likeness, voice, or biographical information and any photos, photo recordings or video tapes taken or any publicity including me at the Event. 

Signature: (You must sign to participate)                                                                                                                    
Parent or Guardian (if under the age of 18) I represent and warrant that I am the legal parent or guardian of the participant name listed and that I have read and fully understood the waiver release and agree for myself and the participant, participant’s heirs, and representatives to be bound there by.

Parent or Guardian Signature: