Name *

First Name

Last Name

Phone *

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Event Waiver *

By completing and returning this registration! form, you agree to abide by the rules of the "Going the Distance Juneteenth Walk." You understand that entering the walk is at your own risk and that no person(s) or organization(s) will be held responsible for any accident, injury or loss to yourself, prior to, during or after the event, you understand the organizers reserve the right to delay or cancel the event in case of adverse weather conditions or other events outside the organizers control. The determination of what constitutes this is reserved solely to the walk organizers. Photographs of the walk and subsequent picnic and entertainment will! be taken for publicity purposes. You understand that your image may be used, and give permission for it to be! used. Children must be accompanied by an adult and are the sole responsibility of the adult at all times during the event.

I have the read above agreement, and understand that by click submit you agree to conditions of the "GOING THE DISTANCE FOR BLACK SCRANTON" waiver and are registering to participate in this event.