Shine The Light

Awareness Walk to Shine the Light on Domestic Violence Registration Form

Saturday, October 13, 2012
Geneva Lakefront
Registration: 6:30 pm
Walk: 7:00 pm
Contact: Virginia Torruella
Phone: 315-781-1093

Name

Address

City

State

Zip Code

Phone

Email

Registration (check one)
 Individual Registration $10 Family Registration $25 (Parents/Guardian and Children Only)

Names and Ages of Participating Family Members

By checking the box below, I waive all claims for myself, minor children and heirs and will not hold Safe Harbors of the Finger Lakes, Inc. or any of the sponsors of this event liable for any injuries or illnesses which may result from my participation in this event. I further state that I am physically able to participate in this walk. I hereby give Safe Harbors of the Finger Lakes, Inc. and various media outlets permission to use my name and/or picture in any media coverage of this event without limitation or further compensation.

 I agree to the above terms and conditions.