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

Team Registration Form

Clearfield Jefferson Walk for Suicide Prevention & Awareness

Please indicate your interest in team participation in the

Clearfield Jefferson Walk for Suicide Prevention & Awareness

® I am interested in organizing a team of walkers.

Name: ___________________________________________________Phone: ___________________

Mailing Address: ____________________________________________________________________

City, State, Zip: _____________________________________________________________________

Team Name (if known): ______________________________________________________________

Our Team Goals are: #of Walkers: _________________ Dollar Amount: _______________________

®I am interested in joining a team of walkers.

Name of team you want to join (if known):_______________________________________________

®Please check those items that apply:

__ I want to be a team member

__ I want to be a primary team captain

__ I will be helping a primary team captain as an assistant team captain.

Please return this form by September 4th:

Mail To:

Clearfield Jefferson Suicide Prevention Team

Attention: Mary Brown

PO Box 344, DuBois, Pa. 15801

Email: mbrown@cljmhmr.com

Fax: 814-265-1049