Walktober 2022 Registration County Of ResidenceAdairCaseyClintonCumberlandGreenMcCrearyPulaskiRussellTaylorWayneFirst Name(Required) Last Name(Required) Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Email(Required) ** Please Read below and sign the Release and Waiver of Liability. Every participant MUST sign this in order to join the event ** . WALKTOBER WAIVER INFORMATION I am voluntarily participating in the Walktober event for Lake Cumberland District Health Department (LCDHD) which includes physical activity. I am aware that participating in the physical activity has RISKS OF INJURY. I understand that the dangers and risk of participating in the Walktober for LCDHD event include, but are not limited to, heart attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, heat prostration, injuries to knees, backs, foot, or any other illness or soreness including death. I understand that the purpose of the Walktober for LCDHD event is to develop and maintain wellness, and decrease stress. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Walktober for LCDHD. I acknowledge that I am in good physical condition and do not know of any condition or reason that I should not be able to participate in physical activity. I understand that I am to listen to the feedback my body is giving me and be responsible for monitoring my own condition throughout the activity. If I should begin to have any pain or discomfort, I will stop my participation and seek medical attention immediately. I also understand in consideration for being allowed to participate in this Walktober for LCDHD event, I agree to assume all risks of such exercise, and waive any claim that I might have arising out of this activity, and further agree to hold harmless Lake Cumberland District Health Department (LCDHD), and any affiliates or any persons/facilities associated with the Walktober event from any and all claims, suits, losses or related causes of action for damages, including, but not limited to, such claims that may result in my injury or death, accidental or otherwise, during or arising in any way from the Walktober event. I understand I have the right to withdraw from the Walktober for LCDHD event at any time without affecting my right to future care or treatment. I give my permission to allow photos of me be used on social media, and other forms of promotion. In signing this consent form, I affirm that I have read this form in its entirety and I understand the nature of the program and sign it voluntarily as my own free act and deed. I also affirm that my questions regarding the Walktober for LCDHD event have been answered to my satisfaction. 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