Last Name:

First Name:

M.I.:

Mailing Address:

City:

State:

Zip Code:

Home Phone:

Email:

Please indicate the organization you are walking to support by selecting no more than two:

American Diabetes Association
Dream Come True of the Lehigh Valley
Equi-librium, Inc. Equine Assisted Services
Family Connection of Easton
Habitat for Humanity of the Lehigh Valley, Inc.
LifePath
Meals on Wheels of Northampton County
ProJeCt of Easton
South Bethlehem Neighborhood Center
The Arc of Lehigh and Northampton Counties
Valley Search and Rescue
Visual Impairment and Blindness Services
Volunteer Center of the Lehigh Valley

T-Shirt Size (requires donation on day of event):

M      L      XL      XXL

I am walking with a team:

My team name is:

My team captain is:

If applicable:

I cannot participate, but please accept my donation.
(Make checks payable to your selected organizations.)

I am a Highmark employee. My mailcode is:

I heard about the walk from:

Participating organization

My employer

Internet

Friend

Highmark employee

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Other:

I hereby waive all claims against Highmark Inc. and all sponsors, charities or personnel involved in the walk for any injury that I might suffer at this event. I attest that I am physically fit and prepared for this event. I grant full permission for Highmark Inc. and participating organizations to use photographs from me in accounts and promotions of this event.

I AGREE TO THE TERMS OF THIS EVENT.

Date: