COME Walk With US…

And Weed Out Elder Abuse!The Piedmont Triad’s 1st Annual World Elder Abuse Awareness Day Walk

“Weeding Out Elder Abuse”June 16, 2012

Registration 8:00 AM; Walk 9:00 AMTriad Park

9652 East Mountain Street, Kernersville, NC 27284Sponsored By: In Partnership With:

With Support From:

WALK

PARTICIPANT FORM

PLEASE PRINT CLEARLY:

Circle One: Individual Walker Walking with a Team/ Team Name: ______________________ NOTE: Each Walk Participant Should Complete This Form, Even If Walking With a Team

Individual Name: _____________________________________________________________________

Address: ____________________________________________________________________________

City: _________________________________ State:_______________ Zipcode:__________________

Telephone #:________________________ Email:__________________________________________

T-Shirt Size (Circle One) SMALL MEDIUM LARGE X-LARGE

Signature: _________________________________________________________________________

Please return this completed form to:

Dorian FredricksenPTRC Area Agency on Aging

2216 West Meadowview Road, Suite 201

Greensboro, NC 27407Fax: (336) 632-0457;

Phone: (336) 294-4950Email: dfredricksen@ptrc.org

Walk participants and volunteers assume all risk associated with the walk.  The walk

organizers are not responsible for potential injuries during the walk.  Minor

children must be accompanied and supervised by an adult.