Last Name:

First Name:

M.I.:

Mailing Address:

City:

State:

Zip Code:

Home Phone:

Email:

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

Achievement Center
Community of Caring
Erie County Diabetes Association
Erie DAWN, Inc.
Erie Homes for Children and Adults
Erie's Promise Student Forum
Erie School District CHAMPS Afterschool Enrichment Program
Greater Erie Community Action Committee (GECAC)
Highmark Caring Foundation
Hispanic American Council
Make-A-Wish Foundation
Mental Health Association of Northwestern Pa.
Presbyterian Homes
Safe Harbor Beheviorial Health
Sarah Reed Children's Center
Second Harvest Food Bank of Northwestern Pa.
Stairways Behavioral Health
St. Martin Center, Inc.
Therapeutic Riding Equestrian Center (TREC)
Vision and Blindness Resources

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.
(Please make check payable and mail to your selected organization.)

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: