Epilepsy Services of Southwest Florida

Southwest Florida Epilepsy Awareness Walk On-line Registration

Saturday, April 21, 2018
Lakes Regional Park, Fort Myers
8:30 am Registration Opens
9:30 am Walk Starts

All participants must register separately.

Name
Address
City
State
Zip
Phone
Email

Epilepsy Awareness Walk Participant (t-shirt & PARKING at Lakes Regional Park is included with registration)

Adult $25.00
Child (under 12) $10.00 - t-shirt included

Child (under 12) $0.00 - t-shirt NOT included
Registration Type
T-shirt size
I want to order an Additional T-shirt for $10.00
T-shirt size

Participant Waiver

I, for myself, my heirs and personal representatives, waive all rights and claims for damages and injury that may occur as a result of my participation in the Southwest Florida Epilepsy Awareness Walk. I attest that I am physically fit and have sufficiently trained to participate in this event. Further, I hereby release the City of Fort Myers, Epilepsy Services of Southwest Florida, all sponsors and their representatives from any and all claims of damages, demands, actions whatsoever in any manner as a result arising from my participation in said race. I agree to allow my name and picture to be used in coverage of this event for legitimate purposes. This event takes place rain or shine. I understand that my registration fee is non-refundable.

Type your name for Electronic Signature
Date

After clicking the submit button you can add another registration or make payment.

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