(* = required)

Registrant Information:

*First Name:
*Last Name:
Parent/Guardian Full Name:	(if participant listed is a minor – under 18 years of age)
*Street:
*City:
*State:
*Zip:
*Phone:
*Email:

*Register for the following walk:

-- Select -- June 22 (Walnut Hill Park, New Britain)

*How did you hear about Walk with a Doc?
(Please check all that apply)

Email
Event flier
Facebook notice
Friends
Newspaper ad
Newspaper article
Website
Other

Please check if you would like to receive emails and/or mailings regarding programs, new services or news related to any or all of these Hartford HealthCare System entities:

Hartford HealthCare:	email	mailing
Hartford Hospital:	email	mailing
The Hospital of Central Connecticut:	email	mailing
MidState Medical Center:	email	mailing
Doctors of Central Connecticut:	email	mailing
Hartford Medical Group:	email	mailing
MidState Medical Group:	email	mailing

*Please Read the Following:

Waiver and Release of Liability

05/25/2013

In this waiver, the term “Just Walk” refers to Just Walk!, Inc., its members, directors, trustees, officers, employees, agents, volunteers, sponsors, representatives, and any persons or entities whose property may be used as part of the Just Walk program. Hartford Healthcare includes its officers, directors and employees as well as all of its system hospitals and affiliates and their officers, directors and employees.

1. Just Walk is a non-competitive program designed to provide general health information and moderate physical exercise in a supportive group environment. I represent that I am in adequate physical condition to participate and that I have consulted my doctor or other health care provider as to any concerns I have regarding my ability to participate safely.
2. I understand that Just Walk and Hartford HealthCare cannot guarantee my safety while attending or participating in the program. I understand that participation in a walking program exposes me to risks such as walking-related injury, traffic injury, injury due to falls and other hazards from walking in different settings, and exposure to hazardous weather conditions and weather related illness.
3. Medical and health information is given from time to time at Just Walk events. I understand that this information is being given in a public venue for general knowledge and is not intended to replace a personal consultation with my doctor or health care provider. I will consult my doctor or health care provider as to any personal health concerns.
4. I understand that it is my responsibility to protect my property while attending Just Walk events and that Just Walk/Hartford HealthCare cannot be responsible for any damage to or loss of such property.
5. I grant permission to Just Walk/Hartford HealthCare to use my name, any photographs, motion pictures, recordings, or any other record of my participation in the Just Walk/Hartford HealthCare program. I release any rights of privacy and/or compensation that I may have in connection with such use.
6. I have carefully read and understand this waiver.

In consideration for my taking part in Just Walk, I, for myself, my heirs, executors, administrators, successors, and assigns, release, waive, and hold harmless Just Walk and Hartford HealthCare from any and all liability, claims, demands, damages, costs, actions and causes of action with respect to death, injury or property damage, however caused, arising out of my participation in the Just Walk program.

I agree to the terms of the Waiver and Release of Liability for myself (or the minor listed above). Authorization is valid for two years from date of above agreement. (download/print this waiver)