Mental Health Awareness Walk 2024 Survey

1.What is your First and Last Name?

2.What is your address?

3.What is your email address?

4.What is your phone number?

5.In which location will you be walking?

Belmont County - Memorial Park

Harrison County - Sally Buffalo

Monroe County - Piatt Park

7.I understand that I am responsible for my person and any persons accompanying me for the walk. I hereby release the East Central Ohio ESC and associated agencies or coalitions from all liability and cost resulting from accidental injuries sustained, transportation rendered, and medical treatment administered to any persons participating in the Courses of Connections walk. By signing this electronic form, I represent that I am in good health and able to safely participate in this event. I acknowledge that there are risks associated with any physical event and that I release all aforementioned parties from risk and liability.

I have read and agree to the above statement.

I do not agree to the liability waiver and acknowledge that I will not be permitted to participate.

8.Media Release Statement: Throughout this event, we may have the opportunity to take photographs or share information via news releases or social media of registrant participation. We ask permission to release photos, names, or other affiliations, as needed, to publicize programming and highlight achievements made by registrants and their accompanying members. Please read and acknowledge the statement below.

I acknowledge that there may be coverage of the Courses of Connection walk event and that my image, or that of my accompanying persons, my be present in various media releases.I agree to the release of my name and/or images, along with any associates, for the purposes of promoting the event.