PLEDGE ENVELOPE & WAIVER FORM Please turn in your Participant Waiver Form and Pledge Envelope at the Walk. One walker per envelope please. Make checks payable to: National Multiple Sclerosis Society. First Name _____________________________________Last Name _________________________________ Address _________________________________________________________________________________ City __________________________________________ State _________________Zip _________________ Phone (H) ___________________________________ (W) ________________________________________ E-Mail ______________________________________________ DOB ______________ Gender ___________
I’m Walking in:
YES
Did you turn in money before today?
Albany
Athens
Atlanta
Augusta
Columbus
Macon
Marietta
Rome
Savannah
NO
Total Money Turning In Today Checks (Total of all checks enclosed) $ _____________ Corporate Matching Gifts
$ _____________
(Total of all checks enclosed)
I’m Walking as:
Cash
$ _____________
(Total cash enclosed. If possible, convert to check or money order.)
An Individual Part of a Team
Total of all monies turning in today
$ _____________
Team Name: ________________ Team Captain: _______________
Will you mail in more money after today?
YES
NO
If known, how much? _____________________________ Waiver of Responsibility: Having read this waiver, I, for myself and anyone entitled to act on my behalf, including heirs and assigns, waive and relieve the National Multiple Sclerosis Society (the “NMSS”), The Georgia Chapter, corporate sponsors, cooperating organizations and any other parties connected with this event in any way together with their respective successors and assigns from all claims or liabilities of any kind arising out of my participation in the Walk MS (the Event) even though such claim or liability may arise out of the negligence or carelessness on the part of any person named in this waiver. I do hereby agree that I am physically capable of participating in this Event. If I do not follow the rules of the Event, I understand that I may be removed from the Event. I consent to receive medical treatment that may be deemed advisable in the event of injury or illness during the Event. I give my permission to the NMSS and its local chapters to use my name, any photographs of me or any other media including video or any other audio format and the NMSS Website during the course of this event.
I agree with the terms and conditions above: Signature: _______________________________________ Date: ___________________________________________
OFFICE USE ONLY
NOTE: Waivers/releases of participants in this event under the age of 18 must be signed by a parent/legal guardian. An adult (21 or older) must also accompany the walkers along the entire route. Checks _________
Initials ________
Cash
_________
Acct # ________
CC
_________
Total
_________