Walk for training, workshops, and education, outreach and support groups. You can help stop the stigma related to suicide in your community. Sunday, September 19^, 2010, DuBois City Park on Liberty Boulevard

Individual Registration Form and Waiver

Clearfield Jefferson Walk for Suicide Prevention & Awareness

Why join our Walk? C/J S.P.T. (Clearfield Jefferson Suicide Prevention Team) is dedicated to reduce the occurrence of suicide within our two county areas. The team wants to achieve this goal by promoting awareness and prevention by offering programs to the community at large. We want to be able to provide prevention, intervention, and postvention trainings to any and all groups from the faith based community to the business community. The team wants to make suicide a topic we can freely talk about and not to be in fear of. We want everyone to learn how to identify the person who may be suicidal and then know what to say to get them the help they so desperately need. Your participation adds strength to our efforts to advocate for solutions and combat stigma.

What is the cost to register? None! Your support is appreciated by joining our Walk.

How can you help? Clearfield Jefferson Suicide Prevention Team is a branch of a non-profit organization. Your tax-deductible donation will help us continue education programs, advocacy for people with mental illnesses and their families. Please designate your pledge amount below.

Registration:

Full Name (print):___________________________________________________________________________

Address: __________________________________________________________________________________

Phone: __________________________________Email: ____________________________________________

Team Name (if on one)._______________________________________________________________________

Donated Amount Pledged: $______________________ (May be given the day of the event)

Donated Amount Enclosed: $______________________

Please make checks payable to: Clearfield Jefferson MH/MR Suicide Prevention Team

Required Waiver of Responsibility for Self:

In consideration for accepting this entry, I, the undersigned, intending to be legally bound, hereby for myself, heirs, and executive administrator, waive and release any and all rights for damages I may have with the Clearfield Jefferson Suicide Prevention Team Walk and verify that I am physically fit to undertake this walk.

Signature_________________________________ Print Full Name_____________________________

Waiver of Responsibility by Parent or Guardian for Underage Walker:

On behalf of ___________________________________ [underage walker], I waive and release the Clearfield Jefferson Suicide Prevention Team as indicated above.

Signature: ________________________________ Print Full Name: ____________________________

Please bring waiver on the day of the event or return this form by mail or fax to :

Fax To: 814-265-1049

Mail To:

Clearfield Jefferson Suicide Prevention Team

Attention: Mary Brown

PO Box 344, DuBois, Pa. 15801