Walk to Win

Participants who are employed or residing in the counties of Calumet, Outagamie, or Winnebago, Wisconsin can participate in Walk to Win. Persons living outside these counties may participate; however they are not eligible for prizes.

Please enter your registration information below:

.ENTRY FORM
* First Name:
Middle Initial:
* Last Name:
* Sex:
* Age:
Parent/Guardian (if child):
* Home Address:
* City:
* State/Zip:	/
* County:
Phone:	###-###-####
Email Address:

PRE-WALK QUESTIONNAIRE

* How often do you currently exercise each week (Sustained activity for 15 minutes or more)?

* How would you rate your general health?

* How did you hear about Walk to Win?

* What is your Walk to Win goal
(check all that apply)

Lose/Maintain Weight
Stress Relief
Manage Diabetes
Lower Blood Pressure
Lower Cholesterol
Other

* LIABILITY AND PUBLIC RELEASE:
Release of Responsibility: I know that exercising is a potentially hazardous activity. I should not enter and walk unless I am medically able. I assume all risks associated with exercising including, but not limited to falls, weather, traffic and conditions of the road, all such risks being known and appreciated by me. Having read this release and knowing these facts, and in consideration of your accepting my registration, I, for myself and anyone entitled to act on my behalf, waive and release the YMCA, government entities, and all partners and sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event.

I agree to these terms

Name of parent or guardian
(if participant is under 18 years of age)

* Specifies required fields