2nd Annual “Cure For Meso” Pub Crawl
Sponsorship Commitment & Individual Registration Form – May 4th, 2013
6:30 PM – 2:00 AM
All Proceeds Donated to – Mesothelioma Applied Research Foundation (MARF)
Corporation/Company/Donor Name/Individual Name: ______
Contact Name for Corporation/Company Sponsor: ______
Title: ______
Mailing Address: ______
City/State/Zip: ______
E-Mail: ______
Phone: ______Fax: ______
Assistant’s Name: ______Assistant’s Phone: ______
Assistant’s E-mail: ______
SPONSORSHIP
_____ $250.00 Corporate SponsorCheck ______
_____ $50.00 Individual AttendeeCash ______
Corporate Sponsorship Includes Company logo on T-shirt, Tickets to the pub crawl and mention in press releases
I am unable to sponsor or attend, but I would like to make a donation to MARF $ ______
Please make checks payable to:
Mesothelioma Applied Research Foundation
1317 King Street
Alexandria, VA 22314
T-Shirt Size: X – Small X – Large
Small XX – Large
Medium XXX – Large
Large
Research*Education*Support*Advocacy
The Mesothelioma Applied Research Foundation is the national non-profit dedicated to ending the suffering caused by Mesothelioma by funding Mesothelioma research, by providing education and support for patients and their families, and by advocating for federal funding of Mesothelioma research.
Waiver of Liability and Release of All Claims
I ______(print name) wish to participate in the "Cure 4 Meso" Pub Crawl. I understand that I am solely responsible for my own health and safety; the decision to participate, the decision to continue participating, whether to drink alcohol, and how much alcohol to drink is exclusively my decision and my responsibility.
I AGREE NOT TO SUE Gori Julian & Associates, P.C., for any damage or harm arising out of or related to my participation in the 1st Annual "Cure 4 Meso" Pub Crawl. The term Gori Julian & Associates, P.C. means not just the law firm but also includes any and all persons associated with the firm and includes all of its principals, officers, representatives, agents, and employees. Neither by sponsoring this activity nor by any other action or representation is Gori Julian & Associates, P.C. undertaking any duty to keep me safe or protect me from harm.
In short I acknowledge:
(1) I am an adult, I am responsible for my own safety and health, and I am participating in the 1st Annual "Cure 4 Meso" Pub Crawl by my own voluntarily choice,
(2) I know there is a risk of serious harm to me and my property by participating in the 1st Annual "Cure 4 Meso" Pub Crawl, and
(3) if I suffer any losses, get hurt or killed, I won’t and can’t make any claim of any sort against Gori Julian & Associates, P.C. Even if Gori Julian & Associates, P.C. is negligent I fully release the firm from all claims.
I understand this Waiver and Release of all claims to be a broad and comprehensive release; I sign it voluntarily. I intend my estate, heirs, and representatives to be bound by this Waiver and Release. I am at least twenty-one (21) years old.
PARTICIPANT’S SIGNATURE: DATE:
______