Avon Foundation

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Personal Information:

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Name:

First Required	Last Required

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Email: Required

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Street 1: Required

Street 2:

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City/State/ZIP:

City Required	State Required	ZIP Required

Country:

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Phone Number: Required

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Gender: Required

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Date of Birth: Required

Date of Birth:

Question - Not Required - Participant #:

A. CONFIDENTIAL MEDICAL INFORMATION

Each question requires a response

1. Have you ever been treated for or are you currently being treated for any of the following conditions? If Yes, please explain in Question 8 below.

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Question - Required - Epilepsy/seizures yes
no

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Question - Required - Asthma/emphysema yes
no

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Question - Required - Bleeding/clotting disorder yes
no

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Question - Required - High blood pressure yes
no

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Question - Required - Heart disease yes
no

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Question - Required - Diabetes yes
no

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Question - Required - 2. Are you pregnant? yes
no

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Question - Required - 3. Have you been hospitalized or had surgery in the past 6 months? If yes, please explain in Question 8 below. yes
no

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Question - Required - 4. Are you currently in, or have you in the past 6 months, completed major medical treatment (e.g. chemotherapy, radiation, etc.)? If yes, please explain in Question 8 below. yes
no

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Question - Required - 5. Do you have any severe allergies (food, environmental, medication)? If yes, please explain in Question 8 below. yes
no

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Question - Required - 6. Do you take daily medication that will require refrigeration on the event? If yes, please explain in Question 8 below. yes
no

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Question - Required - 7. Do you have any significant medical history and/or any special medical requirements during the event we should be aware of? If yes, please explain in Question 8 below. yes
no

Question - Not Required - 8. Please explain your response of yes to Questions 1 through 7:

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Question - Required - I hereby release the above information for the use of the Avon 39 Medical Director and/or any other Medical personnel who might need to provide care to me during the Event. In addition, should any of my medical information change between now and the time of the Event, I will contact my local Walk office (info.houston@avon39.org or 800-510-WALK) to make them aware of those changes.

I agree

B. Medical Insurance and Event Safety

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Question - Required - I understand that the Avon Foundation strongly recommends that I have medical insurance for the Walk. I will bring my medical insurance card with me. I acknowledge that I am solely responsible for procuring and maintaining all medical insurance. I accept full responsibility for any costs incurred for medical treatment due to failure to maintain insurance. I understand that it is ultimately my responsibility to provide payment to any hospital/emergency response technicians/emergency transport company that may provide services to me as a result of injury/illness during the Event.

I agree

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Question - Required - I understand that I must abide by all decisions of the Medical Team and Medical Director regarding my ability to continue to participate in the Event in case of injury, illness or any Medical situation.

I agree

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Question - Required - I acknowledge that I have read, understand and agree to abide by all Avon 39 Safety and Event policies as outlined in the Participant Handbook. I understand that non-adherence to any policy may be grounds for dismissal from the Event.

I agree

C. Waiver

1)	I understand that my agreement to the terms of this Release and Waiver is a prerequisite for participation in the AVON 39 The Walk to End Breast Cancer, including, but not limited to, training walks prior to the Event (collectively, the ìEventî). I further understand that there are risks and dangers, including death, inherent in participating in the Event which consists of a walk of approximately 26.2 to 39.3 miles over two days. My acknowledgement of having read, understood, and agreed to, the terms of this Release and Waiver is signified by affixing my digital signature at the bottom of this form.
2)	As a condition of participating in the Event, I agree to and hereby do (A) assume any and all risks arising out of or in any way relating to my participation in the Event, and, (B) on behalf of myself and my survivors, heirs, estate, executors, personal representatives, and assigns, release and hold harmless (i) Avon Products Foundation, Inc., Avon Products, Inc. and their affiliates, divisions, assigns, successors in interest, agents, servants, contractors, vendors, employees, officers, trustees, and directors, past, present, and future, and each of them, (ii) OP3, Inc., its agents, servants, employees, officers, directors, and assigns, past, present, and future, successors in interest, contractors, vendors (and their agents), and each of them, and (iii) Event sponsors, officials, and volunteers, including training walk leaders, participating communities and clubs and all government and public or quasi-public entities including, but not limited to, the State, county, and local municipalities where each Event takes place (those listed in (i), (ii), and (iii) collectively herein called the ìReleased Partiesî), from any and all claims, damages, liabilities, actions, or causes of action (including without limitation those relating to personal injury, property damage, and/or wrongful death) that I have or may ever have, whether known or unknown, and whether anticipated or unanticipated by me, arising out of a failure to use reasonable care or any other negligent acts related to, arising out of or in any way relating to my participation in the Event or to the use of Photographs (as defined in Section 9 below) or my name, voice, likeness, and biographical information as described in Section 9 below (including claims for invasion of privacy, rights of publicity, defamation, false light, or misappropriation of my name or likeness or similar claim under any legal or equitable theory) (collectively, ìClaimsî). It is understood that ìproperty damageî shall be deemed to mean, without limitation, any claims in respect of my personal property, whether allegedly lost, damaged, stolen or destroyed, and whether left in the care of an employee or agent of a Released Party or otherwise.
3)	The Release and Waiver herein constitute a complete, perpetual, and unconditional release, discharge, and waiver of any and all Claims against the Released Parties.
4)	I understand and agree that the Release and Waiver herein will have the effect of releasing, discharging, waiving, and forever relinquishing any and all Claims under California law (or the laws of any other state that may provide similar benefits) that I may have or have had on my own behalf and on behalf of my survivors, heirs, estate, executors, personal representatives, and assigns, whether past, present, or future, whether known or unknown, and whether anticipated or unanticipated by me, arising out of or in any way relating to my participation in the Event. In making said Release and Waiver, I acknowledge that I have read and understood California Civil Code Section 1542 (quoted below) and expressly and voluntarily waive (on behalf of myself and said survivors, heirs, estate, executors, personal representatives, and assigns) any and all rights I have or may ever have under such Section with respect to any and all Claims released in this Release and Waiver. Specifically, Section 1542 provides:
A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR.
5)	I understand that the Avon Foundation strongly recommends that I have medical insurance for the Event.  I will bring my medical insurance card with me. I acknowledge that I am solely responsible for procuring and maintaining all medical insurance.  I accept full responsibility for any costs incurred for medical treatment due to failure to maintain insurance. I understand that it is ultimately my responsibility to provide payment to any hospital/emergency response technicians/emergency transport company that may provide services to me as a result of injury/illness during the Event. (For Youth Crew members, this document MUST be signed by parent or guardian.)
6)	I understand that I am solely responsible for my health and safety in connection with the Event, and I acknowledge that I am physically capable of participating in and completing the Event.
7)	If a Walker:
a)	I agree to raise at least $1,800 USD before the date of the Event in order to walk in the Event. I understand that if I have not raised the minimum that I may make my own donation to reach that minimum in order to walk in the Event. If I do not reach the $1,800 fundraising minimum, I understand that I cannot walk in the Event.
b)	I will be at least 16 years of age within the calendar year of the Event in which I will participate.
c)	If I will not be at least 18 years of age by the date of the Event, then not only I, but also my parent or legal guardian, must evidence (i) her or his agreement to my participating in the said Event and (ii) her or his agreement, on both her/his behalf and on my behalf, to the terms of my participation in the Event, including, without limitation, the terms of this Release and Waiver. My parent or legal guardian must evidence these agreements by counter signing, along with myself, the front of this registration form.
8)	If a Crew Member:
a)	I understand that I will be an unpaid volunteer at the Event, and that my participation in the Event does not constitute employment. I also understand that I am not required to meet a fundraising minimum in order to participate.
b)	I will be at least 18 years of age by the date of the Event in which I will participate.
9)	I hereby irrevocably grant the Avon Products Foundation, Inc., Avon Products, Inc., OP3, Inc., and their contractors, agents, and sponsors, (A) the right to take photographs and make recordings of me (collectively, ìPhotographsî) during and in connection with the Event and (B) the royalty-free, worldwide, perpetual right to reproduce, distribute, create derivative works of, publicly display and perform the Photographs in all media (now known or later developed) for any purpose related to the Event, including advertising, educational, commercial, and fundraising purposes.
10)	Should any portion of this Release and Waiver be judicially determined to be invalid, voidable, or unenforceable, for any reason, such portion of this Release and Waiver shall be severable from the remaining portions hereof and the invalidity, voidability, or unenforceability thereof shall not affect the validity, effect, enforceability, or interpretation of the remaining provisions of this Release and Waiver. I have carefully read this Release and Waiver and fully understand its contents. I am aware that this is a release of liability and I sign of my own free will.
11)	This Release and Waiver supersedes any prior Releases and Waivers or other understandings, agreements, or representations between or among myself and the Released Parties, written or oral, to the extent they relate to the subject matter hereof.
BY CLICKING "I AGREE WITH THE TERMS AND CONDITIONS ABOVE", I HEREBY AFFIX MY ELECTRONIC SIGNATURE AND INDICATE MY ASSENT TO ALL TERMS AND CONDITIONS IN THIS WAIVER.

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Question - Required - I have read, understand and agree to the Participant Release and Waiver.

I agree

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Question - Required - I hereby release the above information for the use of the Avon 39 Medical Director and/or any other Medical personnel who might need to provide care to me during the Event.

I agree

D. Emergency Contact Information

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Question - Required - First Name

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Question - Required - Last Name

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Question - Required - Daytime Phone

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Question - Required - Evening Phone

Question - Not Required - Other Phone

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Question - Required - Relationship

Question - Not Required - Medical Status

E. Participants who are Minors

(participants who are 16 and 17 years old must have this section completed by their parent or legal guardian):

Question - Not Required - If I will not be at least age 18 years of age by the date of the Event, then not only I but my parent or legal guardian, must evidence her or his agreement on both her/his behalf and on my behalf to the terms of my participating in the Event, including without limitation the terms of the Release in section A, the Medical Insurance and Event Safety waivers in section B, and the liability Waiver in section C of this Medical form. My parent/guardian must evidence these agreements by checking the box below.

As the parent or legal guardian of the participant, I agree to the above.

Question - Not Required - Type name:

Question - Not Required - Tracking data

F. On-Event Emergency Contact

Is there anyone participating in the Walk with you that we may contact in case of emergency?

Question - Not Required - Name

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Mobile Phone Number

G. Confirm Medical Form Data

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Question - Required - I confirm this information is correct

yes

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Medical Form Houston 2015