I Am Walking In Memory Of _______________________________________________________

Name__________________________________________________________________________________

Street Address___________________________________________________________________________

City, State Zip Code ______________________________________________________________________

Telephone__________________  Email  Address___________________________

Pledge Amount*___________________________*Please make checks payable to: BP/USA – AA County

The Anne Arundel County Chapter of The Bereaved Parents of the USA, states that no goods or services were provided in exchange for your contribution. Your contribution is tax-deductible to the extent allowed by law. The Anne Arundel County Chapter of The Bereaved Parents of the USA, is a 501(c)3 tax-exempt not-for-profit organization. Our employer identification number is 36-4081249.

A pledge is not required to participate in the Walk. If you cannot participate in the walk, but would like someone to walk in your child’s memory, please print out and fill in this form and send it along with your pledge to: BPUSA/AA County, P.O. Box 6280, Annapolis, MD 21401-0280

If you have any questions about this event, please send an email to: aacountymemorywalk@gmail.com
or go to our website at www.aacounty-md-bereavedparents.org

LIABILITY WAIVER MUST BE SIGNED BEFORE PARTICIPATING IN MEMORY WALK

WAIVER AND RELEASE: I recognize that participation in the Anne Arundel County Chapter Memory Walk may involve certain hazards. I understand that I should not participate unless medically able. I assume all risks associated with involvement in this activity, including but not limited to falls, contact with participants, the effects of weather, including high heat and humidity, the conditions of the track and/or road, traffic on the course, and all risks being known and appreciated by me. Having read this waiver or release, knowing these facts and in consideration of my acceptance into this Memory Walk, I, for myself and anyone entitled to act on my behalf, waive and release the Anne Arundel County Chapter of The Bereaved Parents of the USA, and all sponsors and hosts, and their representatives and successors from all claims or liabilities of any kind arising from involvement in this activity.

Signature (Parent or Guardian if under 18): __________________________________ Date: ____________