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: [email protected]
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.
