Walk Across Tennessee Registration

WE WILL BE STARTING THIS PROGRAM FEBRUARY 3, 2008

Each individual walker is required to complete this form. The form must be completed before you begin! Start recording miles on February 3rd and track your miles for the next 8 weeks. You can find information in print by clicking on the link above.

First Name

Middle Initial

Last Name

Street

City

State

Zipcode

Telephone

Gender (Please check one)

Female Male

Age (optional)

Ethnic Background (Please check one)

Caucasian African-American Native American Asian Hispanic Other (specify)

My personal goals for walking include: (Check all that apply)

This is the first time I have participated in Walk Across Tennessee

Reducing stress

Controlling blood pressure

Improving blood sugar levels

Improving sleep

Increasing my personal energy

Use walking to help stop smoking

Losing weight

If you checked lose weight how many pounds do you plan to lose over the next 8 weeks?

The NAME of my team is

My team captain is

Waiver

I wish to participate voluntarily in the Walk Across Tennessee physical activity for the purpose of personal fitness. I understand that I should have medical approval from my health care professional if :

I have any chronic health problems such as:

Heart disease
Diabetes
Pain in my heart/an or chest areas
Feel dizzy or have spells of severe dizziness
Have a bone or joint condition, like arthritis, that might be made worse by and exercise program
Have been told by a doctor that I have high blood pressure
Have any physical conditions or problems that might require special attention in an exercise program
Am a male over 45 or a female over 50 and not accustomed to vigorous exercise

By checking the box below you are agreeing that you accept full responsibility for any injuries you may sustain while participating in this program and hold harmless all sponsoring parties.

I have read the statement above and I agree Date

Under age 21, parent or guardian signature is required.

Parent or guardian: I agree to allow my child to participate in this program. I understand that all the same rules and regulations apply. I have read the above statement and I agree.