PB Dialysis Walk-Run Registration Form

PB DIALYSIS Walk/Run Registration Form

November 29, 2026 10.00 am ET Misquamicut Beach, Westerly RI
Name

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Contact Number
Format: (000) 000-0000.
T-shirt Size
Age on Event Date
Price per person is $25.00
In Case of Emergency
Emergency Contact:

First NameLast Name
Relationship
Contact Number
Format: (000) 000-0000.
Release and Waiver of Liability - Assumption of Risk and Indemnity Agreement
In consideration of my participation in the PB Dialysis Walk/Run, I, the undersigned participant, hereby acknowledge and agree to the following:

I release, discharge, and hold harmless the organizers of the 5K Walk/Run, their officers, directors, employees, volunteers, sponsors, and any other persons or organizations associated with the 5K Run from any and all claims, damages, or injuries, including death, that may arise from my participation in the 5K Walk/Run or as a result of my use of any facilities or equipment provided by the 5K Walk/Run.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Payment Amount

prevnext( X )
USDDescription
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
Should be Empty:

PB DIALYSIS Walk/Run Registration Form