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TOGETHER WE CAN A Rush Memorial Hospital Foundation Event Benefiting “Brian’s Cause - A Rush County Cancer Treatment Relief Fund” TOGETHER WE CAN BRIAN’S CAUSE
Saturday, August 24, 2013 9:30 a.m. to NoonRegistration Form (one form per person required) Annual walk to raise money for Rush County residents battling cancer.Name:
City: State: Zip:
Age: Male Female Are you a cancer survivor? Yes No Number of years:
Shirt Size (Please check one): Youth L Adult S M L XL XXL
A donation of $25 or more is required to receive a t-shirt.
Donation Enclosed: $25 $50 $75 $100 Other amount $
Participants under 18 years of age must have a parent or guardian signature.
I acknowledge that activities involving running or walking carry inherent risks of injury and damage to my property and myself and wards. I knowingly assume all
risks, whether known or unknown, of these activities. I hereby release Rush Memorial Hospital, the Rush Memorial Hospital, their trustees, directors, officers,
employees, agents, representatives, volunteers, contractors, heirs, executors, assigns, and successors in interest (hereinafter “Hospital and Foundation”,
collectively) from any and all liability from any act or omission that results in injury or damage to myself, my animals, my property and my wards arising out of my
participation. This release of liability is binding upon my heirs, agents, representatives, personal representative, successors in interest, executors and assigns. I am
also aware that any photographs taken during the event may be used in future publications and I grant the Hospital and the Foundation all rights to use these
photographs in any medium for educational, promotional advertising, or other purposes that support the mission of the Hospital and the Foundation.
Mail or drop off registrations to:
Faith Mock, Rush Memorial Hospital Foundation, PO Box 215, Rushville, IN 46173 765-932-7568