Dipsea Hike/Run Registration

Step 1:  Complete the registration form and send it back to us along with your $25 registration donation. Make your checks payable to Marin Breast Cancer Watch.
Step 2:  Collect donations from donors (family, friends or co-workers). These will be collected the day of the event.
Step 3:  Show up and have fun! Don't forget to bring running/hiking shoes, sunscreen, a hat and water.


I would like to:  Hike _____  Run _____

Tax-deductible Donation:
Name: ________________________________

__$25   __$50   __$100   __Other: $___
Address: _______________________________

Payment Method:
City: _________________________________

__ Check (Payable to Marin Breast Cancer Watch)
State: ______________

__ Visa     __ Mastercard
Zip: _____________

Credit Card No: _________________________
Email: ____________________________

Expiration Date:    /    /
Phone: ___________________________

Name of Card Holder:

__________________________________
_____I'm interested in starting a corporate fundraising team, please send me more information.

Signature:

__________________________________

Mail to:

Marin Breast Cancer Watch
25 Bellam Blvd, Suite 260
San Rafael, CA 94901
(415) 256-9011
Donations are tax-deductible. Marin Breast Cancer Watch will provide receipts upon request.

Release and waiver: I understand and acknowledge that the Dipsea Trail has inherent dangers that no amount of care, caution, instruction or expertise can eliminate and I expressly and voluntarily assume all risk of death or personal injury sustained while participating in the running or walking of the Dipsea Trail; and I hereby forever release and discharge Marin Breast Cancer Watch from any and all liabilities, claims or causes of actions that I may have for injuries and damages arising out of participating in the Dipsea run or walk including by passive or active negligence of Marin Breast Cancer Watch or hidden, latent or obvious risks that may exist on the Dipsea Trail.
Parent/Guardian Waiver for minors: The undersigned parent or natural guardian or legal guardian does hereby represent that he/she is, in fact, authorized to act on behalf of and is acting in such capacity and agrees to save and hold harmless and indemnify each and all parties referred to above from liabilities, loss, claim and damages.

Signature: ________________________________________

Parent/Guardian Signature: ______________________________________