CCWAA September 21st & 28th, 2019
"Walk Anywhere"

The Conquer Chiari Walk Across America is an annual fundraising and awareness event comprised of a series of local walks held on the 3rd and 4th Saturday of September.

The "Walk Anywhere" feature is a way for people who can not participate at one of the organized walk sites to get involved. By registering, you will be given a personal fundraising page which can be used to raise money and spread awareness. Walk Anywhere participants who donate or raise $50 or more by the deadline will have a specially designed T-shirt mailed to them. In addition, any individuals or teams who raise more than $1,000 will be named at the entrance of the Conquer Chiari Research Center. You do NOT have to actually walk on the day of the event, but if you choose to walk through your neighborhood or local park to raise awareness, please be aware you are solely responsible for your own activity.


* - required field      APO/FPO Military Address Instructions

Walk Location: *
Team: 
First Name: *
Last Name: *
Address: *
 
City: *
State: *
Zip Code: *
Email: *
T-Shirt Size:*   Donations of $50 or more. Must register prior to 8/16 to receive a shirt.

Fundraising Page Information
Password: *  min 4 char
Confirm Password: *
Fundraising Goal: *   numbers only, no '$' or ','
Message: (This message will be displayed on your personal fundraising page. It can be changed at a later time.)

Chars Remaining: ---   (Max 3500 chars)
 
Donation Information
You do not have to donate to register. Simply leave blank.
Donation Amount:    numbers only, no '$' or ','
Card Type: 
Card First Name: 
Card Last Name: 
Credit Card #: 
Card Verification #:    What is this?
Expiration: /
 
Waiver and Release
Walkers 18 Years of Age and Older
In consideration for participating in the Walk Across America, I acknowledge that I am an adult of at least 18 years of age. As such an adult, I knowingly and freely assume all such risks of the Walk, both known and unknown, and assume full responsibility for my participation in this volunteer activity. For myself and on behalf of my heirs, assigns, personal representatives and next of kin, I hereby release, indemnify and hold harmless C&S Patient Education Foundation, its Board of Directors, officers, officials, agents, employees, other volunteers, sponsoring agencies, sponsors, and advertisers with respect to any and all injury, death, loss or damage to property or person associated with my presence or participation in the Walk, whether arising from the negligence of C&S Patient Education Foundation or otherwise, to the fullest extent permitted by law.

FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE (under age 18 at time of registration)
This is to certify that I, as parent/guardian with legal responsibility for this minor child, do consent and agree to this release as provided above of C&S Patient Education Foundation and for myself, my child and our heirs, assigns and next of kin, I release and agree to indemnify and hold harmless C&S Patient Education Foundation from any and all liabilities incident to my child's involvement and participation in this Walk as provided above, even if arising from the negligence of C&S Patient Education Foundation or otherwise, to the fullest extent permitted by law.

    

Thanks for your support!

Rick Labuda, Executive Director
director@conquerchiari.org
724-940-0116


APO/FPO Military Address Instructions
  1. For Army, Navy and Marines: Enter Unit Number and Box Number in the "Address" field.
    For Ships: Enter Ship Name and Hull Number.
    For Air Force: Enter PSC Number and Box Number.
  2. In "Address Line 2," enter optional military command or organization name (e.g., USAG J or 2/566 Postal Co.).
  3. In the "City" field, enter APO or FPO.
    Please note: Our fulfillment partners cannot ship to city codes other than APO or FPO for military shipments. Entering a city other than APO or FPO will result in delays in your order being processed, or potentially cancelled. Only enter the city and not a combination of city and state in this field. This will also result in delays/cancellation of your order. (Incorrect: APO AE, AE.) If you are stationed in a war zone, our system also may not recognize your address. Please review your entry for accuracy and check the box to accept terms and conditions to send to your address. This will override our system and allow you to proceed with your order.
  4. On the "State" line, select one of the following:
    AE – Armed Forces Europe, Middle East, Africa and Canada
    AA – Armed Forces Americas
    AP – Armed Forces Pacific
  5. On the "ZIP Code" line, enter the 5-digit ZIP code for the military unit. Your military ZIP code must start with a 0 or 9. Any other zip codes in combination with AE, AA or AP will result in processing delays/cancellation of your order. Your billing address ZIP code (or home address code) cannot be used in place of your military ZIP code.